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Mathai DS, Hull TD, Vando L, Malgaroli M. At-home, telehealth-supported ketamine treatment for depression: Findings from longitudinal, machine learning and symptom network analysis of real-world data. J Affect Disord 2024; 361:198-208. [PMID: 38810787 DOI: 10.1016/j.jad.2024.05.131] [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: 01/22/2024] [Revised: 04/30/2024] [Accepted: 05/25/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Improving safe and effective access to ketamine therapy is of high priority given the growing burden of mental illness. Telehealth-supported administration of sublingual ketamine is being explored toward this goal. METHODS In this longitudinal study, moderately-to-severely depressed patients received four doses of ketamine at home over four weeks within a supportive digital health context. Treatment was structured to resemble methods of therapeutic psychedelic trials. Patients receiving a second course of treatment were also examined. Symptoms were assessed using the Patient Health Questionnaire (PHQ-9) for depression. We conducted preregistered machine learning and symptom network analyses to investigate outcomes (osf.io/v2rpx). RESULTS A sample of 11,441 patients was analyzed, demonstrating a modal antidepressant response from both non-severe (n = 6384, 55.8 %) and severe (n = 2070, 18.1 %) baseline depression levels. Adverse events were detected in 3.0-4.8 % of participants and predominantly neurologic or psychiatric in nature. A second course of treatment helped extend improvements in patients who responded favorably to initial treatment. Improvement was most strongly predicted by lower depression scores and age at baseline. Symptoms of Depressed mood and Anhedonia sustained depression despite ongoing treatment. LIMITATIONS This study was limited by the absence of comparison or control groups and lack of a fixed-dose procedure for ketamine administration. CONCLUSIONS At-home, telehealth-supported ketamine administration was largely safe, well-tolerated, and associated with improvement in patients with depression. Strategies for combining psychedelic-oriented therapies with rigorous telehealth models, as explored here, may uniquely address barriers to mental health treatment.
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Affiliation(s)
- David S Mathai
- The Johns Hopkins University School of Medicine, Center for Psychedelic and Consciousness Research, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, United States of America; Sattva Medicine - Psychiatry/Psychotherapy Practice, Miami, FL, United States of America
| | - Thomas D Hull
- Institute for Psycholinguistics and Digital Health, United States of America
| | | | - Matteo Malgaroli
- NYU Grossman School of Medicine, Department of Psychiatry, New York, NY, United States of America.
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2
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Wang L, Zhao S, Shao J, Su C. The effect and mechanism of low-dose esketamine in neuropathic pain-related depression-like behavior in rats. Brain Res 2024:149117. [PMID: 38977235 DOI: 10.1016/j.brainres.2024.149117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/28/2024] [Accepted: 07/05/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Clinical evidence suggests that Esketamine (ESK) is an effective treatment for depression. However, the effects of Esketamine in treating depression-like behavior induced by neuropathic pain is unclear. The underlying molecular mechanisms require further investigation to provide new therapeutic targets for the treatment of clinical neuropathic pain-related depression. METHODS A neuropathic pain-related depression model was established in rats with spared nerve injury (SNI). Male Sprague-Dawley rats were randomly divided into four groups: Sham Group, SNI group, SNI + Normal Saline (NS) Group and SNI + ESK5mg/kg Group. Mechanical pain thresholds were measured to assess pain sensitivity in SNI rats. On the 14th day after surgery a forced swim test and sucrose preference test were used to evaluate the depressive-like behavior of rats in each group. Further, a proteomic analysis was used to quantify differentially expressed proteins. The Gene Onotology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were analyzed to explore the main protein targets of SNI in the medial prefrontal cortex. The expression of proteins was detected by Western blotting. RESULTS A neuropathic pain-related depression model was established. Compared with the Sham group, the mechanical pain threshold was decreased significantly (13.2 ± 1.0 vs. 0.7 ± 0.01 g n = 8), while immobility on the forced swim test was also decreased (93.1 ± 7.4 vs. 169.5 ± 9.6 s n = 8), and sucrose preference rate was significantly increased (98.8 ± 0.3 vs. 73.1 ± 1.4n = 7) in SNI group rats. Compared with the SNI + NS group, the mechanical pain threshold was not statistically significant, while immobility on the forced swim test was clearly decreased (161.1 ± 11.6 vs. 77.9 ± 5.0 s n = 8), and sucrose preference rate was significantly increased (53.1 ± 8.9 vs. 96.1 ± 1.4n = 7) in SNI + ESK5mg/kg group rats. To further investigate the underlying mechanism, we employed proteomics to identify proteins exhibiting more than a 1.2-fold difference (P < 0.05) in expression levels within each group for subsequent analysis. Relative to the Sham group, 88 downregulated and 104 up-regulated proteins were identified in the SNI group, while 120 and 84 proteins were up- and down-regulated in the Esketamine treatment group compared with the SNI + NS group. Compared with Sham group, the expressions of mGluR5 and Homer1a were up-regulated in the medial prefrontal cortex (mPFC) in SNI group (mGluR5:0.97 ± 0.05 vs 1.47 ± 0.15, Homer1a:1.03 ± 0.06 vs 1.46 ± 0.16n = 6), and down-regulated after intervention with Esketamine (mGluR5:1.54 ± 0.11 vs 1.06 ± 0.07, Homer1a:1.51 ± 0.13 vs 1.12 ± 0.34n = 6). CONCLUSIONS Low-dose Esketamine appeared to relieve depression-like behavior induced by neuropathic pain. The Homer1a-mGluR5 signaling pathway might be the mechanism of antidepressant effect of Esketamine.
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Affiliation(s)
- Lijuan Wang
- Department of Anesthesiology, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/ Hunan Cancer Hospital, Changsha, Hunan, China; Department of Medicine, Hengyang Medical School, University of South China, Hengyang, China
| | - Shuwu Zhao
- Department of Anesthesiology, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/ Hunan Cancer Hospital, Changsha, Hunan, China
| | - Jiali Shao
- Department of Anesthesiology, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/ Hunan Cancer Hospital, Changsha, Hunan, China
| | - Chen Su
- Department of Anesthesiology, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/ Hunan Cancer Hospital, Changsha, Hunan, China.
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Belge JB, Scantamburlo G, Constant E. Are ketamine and its enantiomers the answer to treatment-refractory depression? Expert Rev Neurother 2024:1-4. [PMID: 38932620 DOI: 10.1080/14737175.2024.2373302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/24/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Jean-Baptiste Belge
- Department of Psychiatry, Centre Hospitalier Universitaire de Liège, Liège, Belgium
- Psychoneuroendocrinology Unit, University of Liège, Liège, Belgium
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Gabrielle Scantamburlo
- Department of Psychiatry, Centre Hospitalier Universitaire de Liège, Liège, Belgium
- Psychoneuroendocrinology Unit, University of Liège, Liège, Belgium
| | - Eric Constant
- Department of neuropsychiatry, Centre Hospitalier Spécialisé Notre-Dame des Anges, Liège, Belgium
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Sackeim HA, Aaronson ST, Bunker MT, Conway CR, George MS, McAlister-Williams RH, Prudic J, Thase ME, Young AH, Rush AJ. Update on the assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form-2 (ATHF-SF2). J Psychiatr Res 2024; 176:325-337. [PMID: 38917723 DOI: 10.1016/j.jpsychires.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/09/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024]
Abstract
All definitions of treatment-resistant depression (TRD) require that patients have experienced insufficient benefit from one or more adequate antidepressant trials. Thus, identifying "failed, adequate trials" is key to the assessment of TRD. The Antidepressant Treatment History Form (ATHF) was one of the first and most widely used instruments that provided objective criteria in making these assessments. The original ATHF was updated in 2018 to the ATHF-SF, changing to a checklist format for scoring, and including specific pharmacotherapy, brain stimulation, and psychotherapy interventions as potentially adequate antidepressant treatments. The ATHF-SF2, presented here, is based on the consensus of the ATHF workgroup about the novel interventions introduced since the last revision and which should/should not be considered effective treatments for major depressive episodes. This document describes the rationale for these choices and, for each intervention, the minimal criteria for determining the adequacy of treatment administration. The Supplementary Material that accompanies this article provide the Scoring Checklist, Data Collection Forms (current episode and composite of previous episodes), and Instruction Manual for the ATHF-SF2.
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Affiliation(s)
- Harold A Sackeim
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, USA.
| | - Scott T Aaronson
- Sheppard Pratt Health System and Department of Psychiatry, University of Maryland, Baltimore, MD, USA
| | | | - Charles R Conway
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| | - Mark S George
- Departments of Psychiatry,Neurology,and Neuroscience, Medical University of South Carolina and Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - R Hamish McAlister-Williams
- Northern Centre for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, UK; Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Joan Prudic
- New York State Psychiatric Institute and Department of Psychiatry, Columbia University, New York, NY, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - A John Rush
- Duke-NUS Medical School, Singapore; Duke University, Durham, NC, USA; Texas Tech University, Permian Basin, TX, USA
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Kavakbasi E, Baune BT. Combination of Acute and Maintenance Esketamine Treatment With Adjunctive Long-Term Vagus Nerve Stimulation in Difficult-to-Treat Depression. Neuromodulation 2024; 27:766-773. [PMID: 38340111 DOI: 10.1016/j.neurom.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/05/2023] [Accepted: 12/31/2023] [Indexed: 02/12/2024]
Abstract
INTRODUCTION The antidepressant effect of N-methyl-D-aspartate antagonists is often short lasting, raising the question of the best maintenance strategy, which has remained unanswered. Vagus nerve stimulation (VNS) as a treatment option for refractory and chronic major depression was shown to reduce the need for maintenance treatment sessions in patients receiving electroconvulsive therapy. To our knowledge, there are no published data on the combination of VNS and esketamine in the literature. MATERIALS AND METHODS This is a naturalistic prospective and retrospective observational study in patients treated with long-term VNS owing to difficult-to-treat depression. These patients also have received esketamine maintenance sessions in addition to short-term treatment. We have investigated the need for maintenance esketamine sessions per month after VNS implantation (number of sessions/number of months between visits), the change in depression severity (mean Montgomery-Asberg Depression Rating Scale [MADRS] score), and the number of hospitalizations per month (number of hospitalizations/number of postoperative observation months). Follow-up visits have been scheduled every three months after VNS implantation (follow-up period 12-24 months, mean 17). RESULTS All patients (n = 8, mean age 53.1 years) had severe difficult-to-treat depression (DTD) (mean MADRS at baseline 30.9). Mean number of hospitalizations per month decreased from 0.17 to 0.11 after VNS implantation (p = 0.041, T = 2.030, df = 7). Mean MADRS at 12 months was 18.3 (40.8% MADRS reduction, p = 0.008, T = 3.146, df = 7). Six of eight patients were offered maintenance esketamine treatment. Mean number of esketamine treatment sessions per month and case decreased from 2.3 at the six-month visit to 0.8 at 12 months (p = 0.076, T = 1,690, df = 5) after VNS implantation. Termination of maintenance esketamine was possible in four cases after a mean of 11.5 months. CONCLUSIONS Combination of esketamine and VNS was effective in patients with DTD to relieve disease severity and reduce hospitalizations. The need for esketamine treatment sessions decreased after 6 months of VNS. No safety concerns arose in this study regarding the combination treatment. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT03320304.
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Affiliation(s)
- Erhan Kavakbasi
- Department of Psychiatry, University Hospital Münster, University of Münster, Münster, Germany.
| | - Bernhard T Baune
- Department of Psychiatry, University Hospital Münster, University of Münster, Münster, Germany; Department of Psychiatry, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
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Graeff FG, Joca S, Zangrossi H. Bradykinin actions in the central nervous system: historical overview and psychiatric implications. Acta Neuropsychiatr 2024; 36:129-138. [PMID: 38178717 DOI: 10.1017/neu.2023.57] [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] [Indexed: 01/06/2024]
Abstract
Bradykinin (BK), a well-studied mediator of physiological and pathological processes in the peripheral system, has garnered less attention regarding its function in the central nervous system, particularly in behavioural regulation. This review delves into the historical progression of research focused on the behavioural effects of BK and other drugs that act via similar mechanisms to provide new insights into the pathophysiology and pharmacotherapy of psychiatric disorders. Evidence from experiments with animal models indicates that BK modulates defensive reactions associated with panic symptoms and the response to acute stressors. The mechanisms are not entirely understood but point to complex interactions with other neurotransmitter systems, such as opioids, and intracellular signalling cascades. By addressing the existing research gaps in this field, we present new proposals for future research endeavours to foster a new era of investigation regarding BK's role in emotional regulation. Implications for psychiatry, chiefly for panic and depressive disorders are also discussed.
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Affiliation(s)
- Frederico Guilherme Graeff
- Behavioural Neurosciences Institute (INeC), Ribeirão Preto, SP, Brazil
- Department of Psychology, FFCLRP, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Sâmia Joca
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Helio Zangrossi
- Department of Pharmacology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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Gent EM, Bryan JW, Cleary MA, Clarke TI, Holmwood HD, Nassereddine RO, Salway C, Depla S, Statton S, Krecké J, Morgan CJ. Esketamine combined with a mindfulness-based intervention for individuals with alcohol problems. J Psychopharmacol 2024; 38:541-550. [PMID: 38863284 PMCID: PMC11179319 DOI: 10.1177/02698811241254834] [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] [Indexed: 06/13/2024]
Abstract
BACKGROUND Alcohol use disorder (AUD) is a major public health issue, posing harmful consequences for individuals and society. Recent advances in addiction research have highlighted the therapeutic potential of ketamine-assisted therapy for AUD. However, the exact mechanisms underlying its effectiveness remain unknown. AIMS This double-blind, pilot study aimed to investigate esketamine combined with mindfulness-based intervention (MBI) to examine whether esketamine enhances engagement in MBI for individuals with alcohol misuse problems and whether enhanced engagement has any impact on alcohol-related outcomes. METHODS In all, 28 individuals with alcohol problems were randomly assigned to receive sublingual esketamine hydrochloride (AWKN002: 115.1 mg) or vitamin C (placebo) in an oral thin film and took part in 2 weeks of daily MBI. Participants were assessed on various self-report measures, including mindfulness, engagement in MBI (physical and psychological), alcohol cravings and consumption. RESULTS Esketamine enhanced psychological engagement with a daily MBI, compared to placebo, and led to transient decreases in alcohol cravings. Esketamine also resulted in significantly greater mystical experiences and dissociative states compared to placebo. CONCLUSIONS The findings suggest that esketamine may improve treatment outcomes when combined with mindfulness-based therapies through its ability to increase engagement with meditative practice.
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Affiliation(s)
- Emily M Gent
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Joshua W Bryan
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Maisy A Cleary
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Tegan I Clarke
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Harry D Holmwood
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Rania O Nassereddine
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Chris Salway
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Simon Depla
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Sarah Statton
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Joy Krecké
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
| | - Celia Ja Morgan
- Psychopharmacology and Addiction Research Centre, Haighton Research Centre, University of Exeter St Luke's Campus, Exeter, UK
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Liebe T, Danyeli LV, Sen ZD, Li M, Kaufmann J, Walter M. Subanesthetic Ketamine Suppresses Locus Coeruleus-Mediated Alertness Effects: A 7T fMRI Study. Int J Neuropsychopharmacol 2024; 27:pyae022. [PMID: 38833581 PMCID: PMC11187989 DOI: 10.1093/ijnp/pyae022] [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] [Received: 02/14/2024] [Accepted: 06/03/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND The NMDA antagonist S-ketamine is gaining increasing use as a rapid-acting antidepressant, although its exact mechanisms of action are still unknown. In this study, we investigated ketamine in respect to its properties toward central noradrenergic mechanisms and how they influence alertness behavior. METHODS We investigated the influence of S-ketamine on the locus coeruleus (LC) brain network in a placebo-controlled, cross-over, 7T functional, pharmacological MRI study in 35 healthy male participants (25.1 ± 4.2 years) in conjunction with the attention network task to measure LC-related alertness behavioral changes. RESULTS We could show that acute disruption of the LC alertness network to the thalamus by ketamine is related to a behavioral alertness reduction. CONCLUSION The results shed new light on the neural correlates of ketamine beyond the glutamatergic system and underpin a new concept of how it may unfold its antidepressant effects.
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Affiliation(s)
- Thomas Liebe
- Department of Psychiatry and Psychotherapy, University of Jena, Jena, Germany
- University Clinic for Dermatology, Magdeburg, Germany
| | - Lena Vera Danyeli
- Department of Psychiatry and Psychotherapy, University of Jena, Jena, Germany
- Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health (C-I-R-C), Halle-Jena-Magdeburg, Germany
- Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany
- German Center for Mental Health (DZPG), Partner site Halle-Jena-Magdeburg, Germany
| | - Zümrüt Duygu Sen
- Department of Psychiatry and Psychotherapy, University of Jena, Jena, Germany
- Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health (C-I-R-C), Halle-Jena-Magdeburg, Germany
- Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany
| | - Meng Li
- Department of Psychiatry and Psychotherapy, University of Jena, Jena, Germany
- Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health (C-I-R-C), Halle-Jena-Magdeburg, Germany
- Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany
| | - Jörn Kaufmann
- Department of Psychiatry and Psychotherapy, University of Jena, Jena, Germany
- Department of Neurology, University of Magdeburg, Magdeburg, Germany
| | - Martin Walter
- Department of Psychiatry and Psychotherapy, University of Jena, Jena, Germany
- Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health (C-I-R-C), Halle-Jena-Magdeburg, Germany
- Department of Psychiatry and Psychotherapy, University Tübingen, Tübingen, Germany
- German Center for Mental Health (DZPG), Partner site Halle-Jena-Magdeburg, Germany
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Vos CF, Hemminga WL, Aarnoutse RE, Ruhé HG. Increasing the bioavailability of oral esketamine by a single dose of cobicistat: A case study. Pharmacotherapy 2024; 44:480-484. [PMID: 38819020 DOI: 10.1002/phar.2942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 06/01/2024]
Abstract
AbstractBackgroundIntranasal esketamine is an approved drug for treatment‐resistant depression (TRD); however, it is costly and may result in specific adverse effects. In this single case study, we explored if oral esketamine can be a suitable alternative.MethodsIn collaboration with a 39‐year‐old female with TRD, we compared plasma concentration curves of intranasal (84 mg) and oral (1, 2 and 4 mg/kg) esketamine. Because oral esketamine has a relatively low bioavailability, it results in a different ratio between esketamine and its primary metabolite noresketamine. To increase the bioavailability of oral esketamine, we co‐administered a single dose of the cytochrome P‐450 (CYP) 3A4 inhibitor cobicistat (150 mg).ResultsFor all doses administered, oral esketamine resulted in lower esketamine but higher noresketamine peak plasma concentrations compared with intranasal treatment. Using oral esketamine it was not possible to generate a similar esketamine plasma concentration curve as with the intranasal treatment, except when combined with cobicistat (esketamine 2 mg/kg plus cobicistat 150 mg).ConclusionsOur findings demonstrate that cobicistat effectively increases the bioavailability of oral esketamine. Further research is required in a larger population, especially to investigate the clinical benefit of cobicistat as a booster drug for oral esketamine.
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Affiliation(s)
- Cornelis F Vos
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wietske L Hemminga
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henricus G Ruhé
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
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Chen X, Zhou R, Lan L, Zhu L, Chen C, Zhang X, Han J, Xia L. Comparison of Effects of Propofol Combined with Different Doses of Esketamine for ECT in the Treatment of Depression: A Randomized Controlled Trial Protocol. Neuropsychiatr Dis Treat 2024; 20:1107-1115. [PMID: 38774255 PMCID: PMC11108059 DOI: 10.2147/ndt.s463028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/10/2024] [Indexed: 05/24/2024] Open
Abstract
Objective Major depressive disorder (MDD) is a common mood disorder. Electroconvulsive therapy (ECT) has a significant effect on treatment-resistant MDD. Esketamine may have potential advantages in improving the efficacy of ECT, and the strong affinity of this compound for NMDAR renders it a viable therapeutic option for the management of depression. This study aims to compare the effects of different doses of esketamine combined with propofol anesthesia versus propofol anesthesia alone in ECT, aiming to provide further insights for optimizing ECT and enhancing comprehensive treatment outcomes for depression. Study Design and Methods This study was a prospective, randomized, controlled, double-blind trial involving subjects and evaluators. One hundred eleven patients scheduled for ECT were randomly assigned to three groups. In Group P, propofol at 1mg/kg was administered intravenously. In Group P+E, propofol at a dosage of 0.5mg/kg and esketamine at a dosage of 0.5mg/kg was administered intravenously. Patients in Group P+SE received propofol at a dosage of 0.75mg/kg and esketamine at a dosage of 0.25mg/kg. The same anesthesia protocol was used for the same patient until the end of the last treatment. The primary outcome measures were the Hamilton depression scale (HAMD) and the Patient Health Questionnaire-9 (PHQ-9), the Columbia-Suicide Severity Rating Scale (C-SSRS), and the Digit symbol substitution test (DSST). Secondary outcomes included length of hospital stay, readmission rate, hemodynamic status, recovery, and adverse events. Discussion This study aimed to compare the effects of propofol combined with different doses of esketamine for ECT. The results may provide a better choice for ECT anesthesia.
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Affiliation(s)
- Xuemeng Chen
- Department of Anesthesiology, Deyang People’s Hospital, Deyang City, Sichuan Province, People’s Republic of China
| | - Rui Zhou
- Department of Anesthesiology and Perioperative Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200434, People’s Republic of China
- Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200434, People’s Republic of China
- Clinical Research Center for Anesthesiology and Perioperative Medicine, Tongji University, Shanghai, 200434, People’s Republic of China
| | - Lan Lan
- Department of Anesthesiology, Deyang People’s Hospital, Deyang City, Sichuan Province, People’s Republic of China
| | - Ling Zhu
- Department of Psychosomatic Medicine, Deyang People’s Hospital, Deyang City, Sichuan Province, People’s Republic of China
| | - Cheng Chen
- Department of Psychosomatic Medicine, Deyang People’s Hospital, Deyang City, Sichuan Province, People’s Republic of China
| | - Xianjie Zhang
- Department of Anesthesiology, Deyang People’s Hospital, Deyang City, Sichuan Province, People’s Republic of China
| | - Jia Han
- Department of Anesthesiology, Deyang People’s Hospital, Deyang City, Sichuan Province, People’s Republic of China
| | - Leqiang Xia
- Department of Anesthesiology, Deyang People’s Hospital, Deyang City, Sichuan Province, People’s Republic of China
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Cavaleri D, Riboldi I, Crocamo C, Paglia G, Carrà G, Bartoli F. Evidence from preclinical and clinical metabolomics studies on the antidepressant effects of ketamine and esketamine. Neurosci Lett 2024; 831:137791. [PMID: 38670523 DOI: 10.1016/j.neulet.2024.137791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/15/2024] [Accepted: 04/23/2024] [Indexed: 04/28/2024]
Abstract
The antidepressant effects of ketamine and esketamine are well-documented. Nonetheless, most of the underlying molecular mechanisms have to be uncovered yet. In the last decade, metabolomics has emerged as a useful means to investigate the metabolic phenotype associated with depression as well as changes induced by antidepressant treatments. This mini-review aims at summarizing the main findings from preclinical and clinical studies that used metabolomics to investigate the metabolic effects of subanesthetic, antidepressant doses of ketamine and esketamine and their relationship with clinical response. Both animal and human studies report alterations in several metabolic pathways - including the tricarboxylic acid cycle, glycolysis, the pentose phosphate pathway, lipid metabolism, amino acid metabolism, the kynurenine pathway, and the urea cycle - following the administration of ketamine or its enantiomers. Although more research is needed to clarify commonalities and differences in molecular mechanisms of action between the racemic compound and its enantiomers, these findings comprehensively support an influence of ketamine and esketamine on mitochondrial and cellular energy production, membrane homeostasis, neurotransmission, and signaling. Metabolomics may thus represent a promising strategy to clarify molecular mechanisms underlying treatment-resistant depression and related markers of clinical response to ketamine and esketamine. This body of preclinical and clinical evidence, if further substantiated, has the potential to guide clinicians towards personalized approaches, contributing to new paradigms in the clinical management of depression.
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Affiliation(s)
- Daniele Cavaleri
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy
| | - Ilaria Riboldi
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy
| | - Cristina Crocamo
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy
| | - Giuseppe Paglia
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy
| | - Giuseppe Carrà
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy; Division of Psychiatry, University College London, 149 Tottenham Ct Rd, London W1T 7NF, United Kingdom
| | - Francesco Bartoli
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy.
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12
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Ralston M, Osman A, Suryadevara P, Cleland E. Effect of Ketamine Treatment on Social Withdrawal in Autism and Autism-Like Conditions. Clin Neuropharmacol 2024; 47:97-100. [PMID: 38743603 DOI: 10.1097/wnf.0000000000000591] [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: 05/16/2024]
Abstract
OBJECTIVE Ketamine and esketamine have been used in the field of psychiatry to alleviate conditions such as major depressive disorder. Our objective was to evaluate the current literature on the use of ketamine for symptoms of social withdrawal in autism spectrum disorder (ASD) and autism-like conditions. METHODS A comprehensive search of PubMed and Web of Science was conducted to identify literature involving the use of ketamine to treat symptoms of autism and social withdrawal. Patients with comorbid disorders were also included. RESULTS Two original studies were found, showing mixed results on the use of ketamine for ASD. The use of esketamine found no statistically significant results, whereas the use of intravenous ketamine was shown to alleviate symptoms of social withdrawal especially in the short term. Neither study reported a significant amount of serious adverse events. Five case reports were also included, showing decreased depressive symptoms and evidence of increased social condition. CONCLUSIONS Research on the use of ketamine for ASD and ASD-related conditions is limited. Evidence of improved social condition exists, but further studies should be conducted to increase sample power and test various doses and methods of administration.
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Lou XJ, Qiu D, Ren ZY, Hashimoto K, Zhang GF, Yang JJ. Efficacy and safety of esketamine for perioperative depression in patients undergoing elective surgery: A meta-analysis of randomized controlled trials. Asian J Psychiatr 2024; 95:103997. [PMID: 38492442 DOI: 10.1016/j.ajp.2024.103997] [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: 01/09/2024] [Revised: 02/25/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Depression is a prevalent mood disorder during the perioperative period, with both preoperative concurrent depression and new-onset postoperative depression impacting postoperative recovery. Recent studies have indicated that the dissociative anesthetic esketamine may alleviate perioperative depressive symptoms. OBJECTIVE This meta-analysis aimed to assess the efficacy and safety of esketamine in treating perioperative depression. METHODS We selected randomized controlled trials comparing esketamine to placebo in terms of postoperative depressive symptoms. The primary outcome was postoperative depression scores, with secondary outcomes including the prevalence of postoperative depression, pain scores using the Visual Analogue Scale or Numeric Rating Scale, and incidences of adverse reactions such as nausea/vomiting, dizziness, dreams/nightmares, hallucinations. RESULTS We enrolled a total of 17 studies involving 2462 patients. The esketamine group demonstrated a significant reduction in postoperative depression scores within one week after surgery (SMD -0.47, 95% CI (-0.66, -0.27), P < 0.001) and over the long term (SMD -0.44, 95% CI (-0.79, -0.09), P = 0.01). Furthermore, esketamine significantly decreased the prevalence of postoperative depression both within one week (RR 0.46, 95% CI (0.33, 0.63), P < 0.001) and over the long term (RR 0.50, 95% CI (0.36, 0.70), P < 0.001). Additionally, esketamine effectively relieved pain on the first postoperative day compared to control. However, it also increased the risks of dizziness and hallucinations for a short time. CONCLUSION This meta-analysis suggests that the intraoperative or postoperative application of esketamine could be a potentially effective treatment for perioperative depression, although the increased risk of adverse reactions should be considered.
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Affiliation(s)
- Xue-Jie Lou
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Di Qiu
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Zhuo-Yu Ren
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China
| | - Kenji Hashimoto
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China; Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Chiba 260-8670, Japan.
| | - Guang-Fen Zhang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, China.
| | - Jian-Jun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The first Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China.
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Więdłocha M, Marcinowicz P, Komarnicki J, Tobiaszewska M, Dębowska W, Dębowska M, Szulc A. Depression with comorbid borderline personality disorder - could ketamine be a treatment catalyst? Front Psychiatry 2024; 15:1398859. [PMID: 38742125 PMCID: PMC11089186 DOI: 10.3389/fpsyt.2024.1398859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024] Open
Abstract
Borderline personality disorder (BPD) is diagnosed in 10-30% of patients with major depressive disorder (MDD), and the frequency of MDD among individuals with BPD reaches over 80%. The comorbidity of MDD and BPD is associated with more severe depressive symptoms and functional impairment, higher risk of treatment resistance and increased suicidality. The effectiveness of ketamine usage in treatment resistant depression (TRD) has been demonstrated in numerous studies. In most of these studies, individuals with BPD were not excluded, thus given the high co-occurrence of these disorders, it is possible that the beneficial effects of ketamine also extend to the subpopulation with comorbid TRD and BPD. However, no protocols were developed that would account for comorbidity. Moreover, psychotherapeutic interventions, which may be crucial for achieving a lasting therapeutic effect in TRD and BPD comorbidity, were not included. In the article, we discuss the results of a small number of existing studies and case reports on the use of ketamine in depressive disorders with comorbid BPD. We elucidate how, at the molecular and brain network levels, ketamine can impact the neurobiology and symptoms of BPD. Furthermore, we explore whether ketamine-induced neuroplasticity, augmented by psychotherapy, could be of use in alleviating core BPD-related symptoms such as emotional dysregulation, self-identity disturbances and self-harming behaviors. We also discuss the potential of ketamine-assisted psychotherapy (KAP) in BPD treatment. As there is no standard approach to the application of ketamine or KAP in individuals with comorbid TRD and BPD, we consider further research in the field as imperative. The priorities should include development of dedicated protocols, distinguishing subpopulations that may benefit most from such treatment and investigating factors that may influence its effectiveness and safety.
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Affiliation(s)
- Magdalena Więdłocha
- Department of Psychiatry, Faculty of Health Sciences, Medical University of Warsaw, Pruszkow, Masovian, Poland
| | - Piotr Marcinowicz
- Department of Psychiatry, Faculty of Health Sciences, Medical University of Warsaw, Pruszkow, Masovian, Poland
| | - Jan Komarnicki
- Leszek Giec Upper-Silesian Medical Centre of the Medical University of Silesia, Katowice, Poland
| | | | - Weronika Dębowska
- Department of Psychiatry, Faculty of Health Sciences, Medical University of Warsaw, Pruszkow, Masovian, Poland
| | - Marta Dębowska
- Department of Psychiatry, Faculty of Health Sciences, Medical University of Warsaw, Pruszkow, Masovian, Poland
| | - Agata Szulc
- Department of Psychiatry, Faculty of Health Sciences, Medical University of Warsaw, Pruszkow, Masovian, Poland
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15
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Sandström K, Kampman O, Asellus P. A retrospective analysis of iv ketamine outcome on hospitalisations in an unselected psychiatric sample. Acta Neuropsychiatr 2024:1-7. [PMID: 38659205 DOI: 10.1017/neu.2024.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE This study aims to explore the outcome with iv ketamine treatment in a real-world clinical setting, primarily measured as posttreatment days hospitalised. METHODS The psychiatric medical records of 46 patients having received iv ketamine on a psychiatric treatment indication between 2015 and 2018 were retrospectively examined. Analysis comparing the number and duration of hospital admissions before and after ketamine treatment as well as logistic regression analysis to investigate clinical predictors of effectiveness, were performed. To assess patients' severity of depressed symptoms records were screened for MADRS-S scores. RESULTS No significant difference between pre- and posttreatment hospital days (p = 0.170), or number of hospitalisations (p = 0.740) were found. The response rate was 31% and remission rate 21%. None of the predictors showed statistical significance in the logistic model. CONCLUSION Iv ketamine treatment showed effectiveness in reducing depressive symptoms even with complex patients in a real-world clinical setting. However, this did not translate to a reduction in hospitalisation. Highlighting the multifaceted challenges posed when implementing iv ketamine treatment in clinical practice.
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Affiliation(s)
- Karl Sandström
- Department of Clinical Sciences (Psychiatry), Umeå University, Umeå, Sweden
| | - Olli Kampman
- Department of Clinical Sciences (Psychiatry), Umeå University, Umeå, Sweden
- Faculty of Medicine, Department of Clinical Medicine (Psychiatry), University of Turku, Turku, Finland
- Department of Psychiatry, The Wellbeing Services County of Ostrobothnia, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Psychiatry, The Pirkanmaa Wellbeing Services County, Tampere, Finland
| | - Peter Asellus
- Department of Clinical Sciences (Psychiatry), Umeå University, Umeå, Sweden
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16
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Zhao LY, Zhang GF, Lou XJ, Hashimoto K, Yang JJ. Ketamine and its enantiomers for depression: a bibliometric analysis from 2000 to 2023. Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01809-9. [PMID: 38662093 DOI: 10.1007/s00406-024-01809-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
Ketamine has demonstrated rapid and sustained antidepressant effects, marking its emergence as an innovative treatment of depression. Despite the growing number of preclinical and clinical studies exploring the antidepressant effects of ketamine and its enantiomers, a comprehensive bibliometric analysis in this field has yet to be conducted. This study employs bibliometric methods and visualization tools to examine the literature and identify key topics related to the antidepressant effects of ketamine and its enantiomers. We sourced publications on the antidepressant effects of ketamine and its enantiomers from the Web of Science Core Collection (WOSCC) database, covering the period from 2000 to 2023. Tools such as VOSviewer, CiteSpace and the R package "bibliometrix" were utilized for visual analysis. The study included 4,274 publications, with a notable increase in publications peaking in 2022. Co-occurrence analysis highlighted two primary research focal points: the efficacy and safety of ketamine and its enantiomers in treating depression, and the mechanisms behind their antidepressant effects. In conclusion, this analysis revealed a significant increase in research on the antidepressant effects of ketamine and its enantiomers over the past two decades, leading to the approval of esketamine nasal spray for treatment-resistant depression. The rapid antidepressant effects of ketamine have spurred further studies into its mechanisms of action and the search for new antidepressants with fewer side effects.
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Affiliation(s)
- Li-Yuan Zhao
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Guang-Fen Zhang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Xue-Jie Lou
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Kenji Hashimoto
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, 260-8670, Japan.
| | - Jian-Jun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
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17
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Millen AME, Daniels WMU, Baijnath S. Depression, an unmet health need in Africa: Understanding the promise of ketamine. Heliyon 2024; 10:e28610. [PMID: 38601594 PMCID: PMC11004535 DOI: 10.1016/j.heliyon.2024.e28610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 04/12/2024] Open
Abstract
In Africa, there is currently a paucity of data on the epidemiology of depression, its treatment and management. The prevalence of depression is severely underestimated, with unique circumstances and societal risk factors associated with depression and its public awareness. Treating and managing depression is confounded by an inaccessibility to efficient and low-cost treatments for patients with depression. The aetiology of depression is multifactorial, with various theories implicating multiple neuronal networks. Despite this, the treatment of depression is one-dimensional focussing on outdated theories of depression and mainly targeting dysfunctional neurotransmitter pathways. Hence, it is not surprising that there is a significant increase in the prevalence of patients suffering from treatment resistant depression (TRD), with a large portion of patients deriving little clinical benefit from these traditional anti-depressant therapies. This highlights the need for more effective treatment strategies for depression, especially applicable to resource limited environments such as Africa, where there is little investment in public healthcare resources towards managing mental health disorders. The clinical potential of using ketamine in managing depression has received considerable attention in the past two decades, with the FDA approving esketamine for the management of TRD in 2019. This widespread attention has significantly increased ketamine's appeal as a novel antidepressant. Consequently, many ketamine infusion clinics have been established in Africa. However, there is little regulation or guidance for ketamine infusions. Furthermore, while esketamine is expensive and hence inaccessible to a large portion of the African population, racemic ketamine is significantly cheaper and has demonstrated clinical potential. However, there is currently a limited understanding of the neurological mechanisms of action of racemic ketamine in treating and managing depression, especially in a diverse African population. Therefore, this review aims to provide an African context of depression and the therapeutic potential of ketamine by highlighting aspects of its molecular mechanism of action.
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Affiliation(s)
- Aletta ME. Millen
- Integrated Molecular Physiology Research Initiative, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - William MU. Daniels
- School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sooraj Baijnath
- Integrated Molecular Physiology Research Initiative, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Willinger D, Häberling I, Ilioska I, Berger G, Walitza S, Brem S. Weakened effective connectivity between salience network and default mode network during resting state in adolescent depression. Front Psychiatry 2024; 15:1386984. [PMID: 38638415 PMCID: PMC11024787 DOI: 10.3389/fpsyt.2024.1386984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Adolescent major depressive disorder (MDD) is associated with altered resting-state connectivity between the default mode network (DMN) and the salience network (SN), which are involved in self-referential processing and detecting and filtering salient stimuli, respectively. Using spectral dynamical causal modelling, we investigated the effective connectivity and input sensitivity between key nodes of these networks in 30 adolescents with MDD and 32 healthy controls while undergoing resting-state fMRI. We found that the DMN received weaker inhibition from the SN and that the medial prefrontal cortex and the anterior cingulate cortex showed reduced self-inhibition in MDD, making them more prone to external influences. Moreover, we found that selective serotonin reuptake inhibitor (SSRI) intake was associated with decreased and increased self-inhibition of the SN and DMN, respectively, in patients. Our findings suggest that adolescent MDD is characterized by a hierarchical imbalance between the DMN and the SN, which could affect the integration of emotional and self-related information. We propose that SSRIs may help restore network function by modulating excitatory/inhibitory balance in the DMN and the SN. Our study highlights the potential of prefrontal-amygdala interactions as a biomarker and a therapeutic target for adolescent depression.
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Affiliation(s)
- David Willinger
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
- Department of Psychology and Psychodynamics, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Isabelle Häberling
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
| | - Iva Ilioska
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Gregor Berger
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Silvia Brem
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
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19
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Vestring S, Galuba V, Kern E, Voita S, Berens F, Nasiri D, Domschke K, Normann C. Ketamine in multiple treatment-resistant depressed inpatients: A naturalistic cohort study. J Affect Disord 2024; 350:895-899. [PMID: 38266928 DOI: 10.1016/j.jad.2024.01.165] [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: 08/17/2023] [Revised: 12/02/2023] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Ketamine has emerged as an effective treatment option for patients with treatment-resistant depression. However, there is limited evidence of the benefits of ketamine in inpatients with multiple treatment resistance (MTR), who far exceed the formal criteria for treatment resistance and suffer from extensive psychiatric comorbidities. OBJECTIVE The aim of this naturalistic study was to provide preliminary evidence for the use of ketamine in the treatment of MTR depression in a naturalistic inpatient setting. METHODS Seventy-seven patients (mean age 45.1 ± 13.8 years) were treated with intravenous or intranasal ketamine (1068 administrations) twice weekly for five weeks, followed by maintenance therapy if clinically indicated. Treatment effects were assessed with the BDI, and side effects were assessed by clinicians. We analyzed dose- and route of application-related changes in depression severity, response and remission rates as well as effects on suicidality and frequency of adverse events. RESULTS Depression severity and suicidality decreased in the acute treatment phase and these changes persisted during the maintenance therapy phase. A total of 28.9 % of the patients met the criteria for response, and 15 % met the criteria for remission. The initial treatment response was highly predictive of the outcome at the end of the acute treatment phase. None of the reported side effects required medical intervention. High-dose intravenous ketamine (0.75-1 mg/kg) resulted in the most pronounced clinical effects. LIMITATIONS This observational, retrospective, and naturalistic study may be subject to bias and did not allow control of external variables. CONCLUSIONS We outlined a clinically feasible, high-dose ketamine treatment regimen for hospitalized patients with MTR depression.
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Affiliation(s)
- Stefan Vestring
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viktoria Galuba
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elisa Kern
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sabine Voita
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Franziska Berens
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Danial Nasiri
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Neuromodulation, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claus Normann
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Neuromodulation, Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Smith-Apeldoorn SY, Veraart JKE, Kamphuis J, Spijker J, van der Meij A, van Asselt ADI, Aan Het Rot M, Schoevers RA. Oral esketamine in patients with treatment-resistant depression: a double-blind, randomized, placebo-controlled trial with open-label extension. Mol Psychiatry 2024:10.1038/s41380-024-02478-9. [PMID: 38523183 DOI: 10.1038/s41380-024-02478-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/23/2024] [Accepted: 02/05/2024] [Indexed: 03/26/2024]
Abstract
About one-third of patients with depression do not achieve adequate response to current treatment options. Although intravenous and intranasal administrations of (es)ketamine have shown antidepressant properties, their accessibility and scalability are limited. We investigated the efficacy, safety, and tolerability of generic oral esketamine in patients with treatment-resistant depression (TRD) in a randomized placebo-controlled trial with open-label extension. This study consisted of 1) a six-week fixed low-dose treatment phase during which 111 participants received oral esketamine 30 mg or placebo three times a day; 2) a four-week wash-out phase; and 3) an optional six-week open-label individually titrated treatment phase during which participants received 0.5 to 3.0 mg/kg oral esketamine two times a week. The primary outcome measure was change in depressive symptom severity, assessed with the Hamilton Depression Rating Scale (HDRS17), from baseline to 6 weeks. Fixed low-dose oral esketamine when compared to placebo had no benefit on the HDRS17 total score (p = 0.626). Except for dizziness and sleep hallucinations scores, which were higher in the esketamine arm, we found no significant difference in safety and tolerability aspects. During the open-label individually titrated treatment phase, the mean HDRS17 score decreased from 21.0 (SD 5.09) to 15.1 (SD 7.27) (mean difference -6.0, 95% CI -7.71 to -4.29, p < 0.001). Our results suggest that fixed low-dose esketamine is not effective in TRD. In contrast, individually titrated higher doses of oral esketamine might have antidepressant properties.
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Affiliation(s)
- Sanne Y Smith-Apeldoorn
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Jolien K E Veraart
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Psychiatry, PsyQ Haaglanden, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Jeanine Kamphuis
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Spijker
- Depression Expertise Center, Pro Persona Mental Health Care, Nijmegen, The Netherlands
- Behavioral Science Institute, Radboud University, Nijmegen, The Netherlands
| | | | - Antoinette D I van Asselt
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marije Aan Het Rot
- Department of Psychology, University of Groningen, Groningen, The Netherlands
- School of Behavioral and Cognitive Neurosciences, University of Groningen, Groningen, The Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- School of Behavioral and Cognitive Neurosciences, University of Groningen, Groningen, The Netherlands
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Vande Casteele T, Laroy M, Van Cauwenberge M, Koole M, Dupont P, Sunaert S, Van den Stock J, Bouckaert F, Van Laere K, Emsell L, Vandenbulcke M. Preliminary evidence for preserved synaptic density in late-life depression. Transl Psychiatry 2024; 14:145. [PMID: 38485934 PMCID: PMC10940592 DOI: 10.1038/s41398-024-02837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 03/18/2024] Open
Abstract
Late-life depression has been consistently associated with lower gray matter volume, the origin of which remains largely unexplained. Recent in-vivo PET findings in early-onset depression and Alzheimer's Disease suggest that synaptic deficits contribute to the pathophysiology of these disorders and may therefore contribute to lower gray matter volume in late-life depression. Here, we investigate synaptic density in vivo for the first time in late-life depression using the synaptic vesicle glycoprotein 2A receptor radioligand 11C-UCB-J. We included 24 currently depressed adults with late-life depression (73.0 ± 6.2 years, 16 female, geriatric depression scale = 19.5 ± 6.8) and 36 age- and gender-matched healthy controls (70.4 ± 6.2 years, 21 female, geriatric depression scale = 2.7 ± 2.9) that underwent simultaneous 11C-UCB-J positron emission tomography (PET) and 3D T1- and T2-FLAIR weighted magnetic resonance (MR) imaging on a 3-tesla PET-MR scanner. We used analyses of variance to test for 11C-UCB-J binding and gray matter volumes differences in regions implicated in depression. The late-life depression group showed a trend in lower gray matter volumes in the hippocampus (p = 0.04), mesial temporal (p = 0.02) and prefrontal cortex (p = 0.02) compared to healthy control group without surviving correction for multiple comparison. However, no group differences in 11C-UCB-J binding were found in these regions nor were any associations between 11C-UCB-J and depressive symptoms. Our data suggests that, in contrast to Alzheimer's Disease, lower gray matter volume in late-life depression is not associated with synaptic density changes. From a therapeutic standpoint, preserved synaptic density in late-life depression may be an encouraging finding.
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Affiliation(s)
- Thomas Vande Casteele
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Neuropsychiatry, B-3000, Leuven, Belgium.
| | - Maarten Laroy
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Neuropsychiatry, B-3000, Leuven, Belgium
| | - Margot Van Cauwenberge
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Neuropsychiatry, B-3000, Leuven, Belgium
- Neurology, University Hospitals Leuven, B-3000, Leuven, Belgium
| | - Michel Koole
- KU Leuven, Leuven Brain Institute, Department of Imaging and Pathology, Nuclear Medicine, B-3000, Leuven, Belgium
| | - Patrick Dupont
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Laboratory for Cognitive Neurology, B-3000, Leuven, Belgium
| | - Stefan Sunaert
- KU Leuven, Leuven Brain Institute, Department of Imaging and Pathology, Translational MRI, B-3000, Leuven, Belgium
- Radiology, University Hospitals Leuven, B-3000, Leuven, Belgium
| | - Jan Van den Stock
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Neuropsychiatry, B-3000, Leuven, Belgium
- Geriatric Psychiatry, University Psychiatric Center KU Leuven, B-3000, Leuven, Belgium
| | - Filip Bouckaert
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Neuropsychiatry, B-3000, Leuven, Belgium
- Geriatric Psychiatry, University Psychiatric Center KU Leuven, B-3000, Leuven, Belgium
| | - Koen Van Laere
- KU Leuven, Leuven Brain Institute, Department of Imaging and Pathology, Nuclear Medicine, B-3000, Leuven, Belgium
- Nuclear Medicine, University Hospitals Leuven, B-3000, Leuven, Belgium
| | - Louise Emsell
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Neuropsychiatry, B-3000, Leuven, Belgium
- KU Leuven, Leuven Brain Institute, Department of Imaging and Pathology, Translational MRI, B-3000, Leuven, Belgium
- Geriatric Psychiatry, University Psychiatric Center KU Leuven, B-3000, Leuven, Belgium
| | - Mathieu Vandenbulcke
- KU Leuven, Leuven Brain Institute, Department of Neurosciences, Neuropsychiatry, B-3000, Leuven, Belgium
- Geriatric Psychiatry, University Psychiatric Center KU Leuven, B-3000, Leuven, Belgium
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Whitaker T, Farrand KF, Thase ME. A Phase 2 Open Label Study of Efficacy, Safety, and Tolerability of SLS-002 (Intranasal Racemic Ketamine) in Adults with MDD at Imminent Risk of Suicide. PSYCHOPHARMACOLOGY BULLETIN 2024; 54:8-17. [PMID: 38449472 PMCID: PMC10913863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Background Despite the prevalence of Major Depressive Disorder (MDD) and the propensity of affected individuals to eventually die by suicide, there is no therapeutic approved specifically for suicidal ideation and behavior (SI/B) in MDD. The NMDA receptor antagonist ketamine has been investigated for the treatment of depression and shown to have a rapid effect on symptoms. Spravato® (esketamine) is approved by the FDA for use in treatment-resistant depression and Major Depressive Episodes with Suicidal Ideation based on studies conducted in adults also taking standard antidepressants. While esketamine was associated with a large reduction in suicidality indicators, the effects did not significantly exceed those associated with placebo. Racemic ketamine, a mixture of both esketamine and arketamine, may hold greater potential for the rapid alleviation of SI/B. SLS-002 was developed as an investigational intranasal racemic ketamine for the treatment of SI/B in individuals with MDD. Methods In part one of a two-part clinical trial, the safety, tolerability, and potential effectiveness of SLS-002 were evaluated in an open label study of 17 patients with MDD hospitalized with acute SI/B. Results Treatment with SLS-002 was associated with a significant reduction in depression and suicidality indicators on four clinical scales: the Montgomery-Åsberg Depression Rating Scale, the Sheehan-Suicidality Tracking Scale, and the Clinical and Patient Global Impression Scales for SI/B. SLS-002 was well tolerated with an acceptable safety profile. Conclusions The results of this open label study support the continued development of SLS-002. The randomized double-blind placebo-controlled part two of this trial was recently completed.
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Affiliation(s)
- Timothy Whitaker
- Whitaker, MD, Chief Medical Officer, Head of Research & Development, Seelos Therapeutics, Inc., New York, NY
| | - Kimberly F Farrand
- Farrand, MPH, Senior Director, Clinical Development, Seelos Therapeutics, Inc., New York, NY
| | - Michael E Thase
- Thase, MD, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA and Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA
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23
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Barnett BS. Formulary Coverage of Esketamine and Ketamine for Depression in Ohio Health Insurance Marketplace and Medicaid Plans. J Psychiatr Pract 2024; 30:130-133. [PMID: 38526400 DOI: 10.1097/pra.0000000000000766] [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] [Indexed: 03/26/2024]
Abstract
For more than 2 decades, intravenous ketamine has been demonstrated to have rapid antidepressant effects. However, access to this generic drug is limited due to insurers claiming it is "experimental" because ketamine does not have a Food and Drug Administration indication for depression. In contrast, intranasal esketamine, an enantiomer of ketamine, is approved by the Food and Drug Administration for depression and is still under patent. The goal of this column is to provide a clearer understanding of formulary coverage of these similar medications by insurers. Formularies of all 2023 Ohio Health Insurance Marketplace and Medicaid plans were reviewed to determine the inclusion status of intravenous ketamine and intranasal esketamine for depression. This review found that intravenous ketamine was not covered by any Marketplace or Medicaid plan for depression, while intranasal esketamine was on 72.7% and 100% of formularies, respectively. Thus, members of the analyzed insurance plans can more easily access intranasal esketamine than intravenous ketamine for depression, despite the latter being more cost-effective and possibly more efficacious.
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Affiliation(s)
- Brian S Barnett
- BARNETT: Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH
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Elersič K, Banjac A, Živin M, Zorović M. Behavioral sensitization and tolerance induced by repeated treatment with ketamine enantiomers in male Wistar rats. PLoS One 2024; 19:e0299379. [PMID: 38427622 PMCID: PMC10906899 DOI: 10.1371/journal.pone.0299379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/08/2024] [Indexed: 03/03/2024] Open
Abstract
Ketamine has gained significant attention as a fast-acting antidepressant. However, ketamine is also associated with undesirable side effects. In our preclinical study, we explored the behavioral effects of ketamine enantiomers at subanesthetic doses. During repeated intermittent treatment, we examined locomotor stimulation and sensitization, ataxia, and expression of natural behaviors (grooming and rearing). Male Wistar rats were subcutaneously treated repeatedly with either 5 mg/kg of R-ketamine or S-ketamine, 15 mg/kg of R-ketamine, S-ketamine or racemic ketamine, 30 mg/kg of racemic ketamine or saline every third day for three weeks (seven treatments overall). After the first treatment, only 15 mg/kg of S-ketamine induced locomotor stimulation, and both 15 mg/kg of S-ketamine and 30 mg/kg of racemic ketamine induced ataxia. Upon repeated administration, doses of 15 mg/kg of R-ketamine, S-ketamine, and racemic ketamine, as well as 30 mg/kg of racemic ketamine, stimulated locomotion. 15 mg/kg of R-ketamine, S-ketamine, and racemic ketamine additionally resulted in locomotor sensitization. The last administration of 15 mg/kg of S-ketamine, 15 mg/kg of racemic ketamine, and 30 mg/kg of racemic ketamine resulted in ataxia. In the case of 15 mg/kg of S-ketamine, ataxic effects were significantly weaker in comparison to the effects from the first administration, indicating tolerance. Natural behaviors were attenuated after 5 and 15 mg/kg of S-ketamine and 15 and 30 mg/kg of racemic ketamine. Neither of the R-ketamine doses produced such an effect. We conclude that S-ketamine has a stronger behavioral effect than R-ketamine.
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Affiliation(s)
- Kristian Elersič
- Brain Research Lab, Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Anamarija Banjac
- Brain Research Lab, Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marko Živin
- Brain Research Lab, Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Zorović
- Brain Research Lab, Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Zhang L, Xu L. Role of Flt3l and Rps15 in ketamine anesthesia. Medicine (Baltimore) 2024; 103:e37123. [PMID: 38428846 PMCID: PMC10906617 DOI: 10.1097/md.0000000000037123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/09/2024] [Indexed: 03/03/2024] Open
Abstract
Ketamine is the only intravenous narcotic that has sedative, analgesic, and anesthetic effects. However, the role of Flt3l and ribosomal protein S15 (Rps15) in ketamine anesthesia remains unclear. GSE26364 and GSE93041 were downloaded from gene expression omnibus. Multiple datasets were merged and batched. Differentially expressed genes (DEGs) were screened and weighted gene co-expression network analysis was performed. Construction and analysis of protein-protein interaction network. Gene ontology (GO) and Kyoto Encyclopedia of Gene and Genome were performed. A heat map of gene expression was drawn. TargetScan was used to screen miRNAs regulating DEGs. 882 DEGs were identified. According to the GO analysis, these DEGs were mainly enriched in cell differentiation, extracellular region, and cytoplasm. The Kyoto Encyclopedia of Gene and Genome analysis revealed enrichment in pathways such as the PPAR signaling pathway, TNF signaling pathway, Hippo signaling pathway, and IL-17 signaling pathway. In the Metascape enrichment analysis, GO enrichment categories included leukocyte differentiation, negative regulation of CREB transcription factor activity, and positive regulation of cell cycle. The protein-protein interaction network showed 10 core genes (Rpl7, Rpl18, Rps15, Rpl7l1, Flt3l, Rps16, Eprs, Rps19, Rps28, Rplp2).Gene expression heatmap showed that core genes (Rplp2, Flt3l, Rps15) were highly expressed in samples treated with ketamine anesthesia. Flt3l and Rps15 are highly expressed during ketamine anesthesia, and may be molecular targets.
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Affiliation(s)
- Lin Zhang
- Department of Anesthesiology, The Third Affiliated Hospital of Beijing University of Chinese Medicine, Anwai, Chaoyang District, Beijing, China
| | - Lingyan Xu
- Department of Disease Control and Prevention, The Third Affiliated Hospital of Beijing University of Chinese Medicine, Anwai, Chaoyang District, Beijing, China
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26
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Serretti A. Modulating factors in mood disorders treatment. Int Clin Psychopharmacol 2024; 39:47-50. [PMID: 38299310 DOI: 10.1097/yic.0000000000000534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
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d'Andrea G, Pettorruso M, Di Lorenzo G, Rhee TG, Chiappini S, Carullo R, Barlati S, Zanardi R, Rosso G, Di Nicola M, Andriola I, Marcatili M, Clerici M, Dell'Osso BM, Sensi SL, Mansur RB, Rosenblat JD, Martinotti G, McIntyre RS. The rapid antidepressant effectiveness of repeated dose of intravenous ketamine and intranasal esketamine: A post-hoc analysis of pooled real-world data. J Affect Disord 2024; 348:314-322. [PMID: 38145840 DOI: 10.1016/j.jad.2023.12.038] [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] [Received: 09/14/2023] [Revised: 11/30/2023] [Accepted: 12/13/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Intravenous ketamine (KET-IV) and intranasal esketamine (ESK-NS) are effective in the acute treatment of Treatment-Resistant Depression (TRD). Studies comparing KET-IV and ESK-NS concerning their action, safety, and tolerability are currently lacking. MATERIALS AND METHODS We combined patients' data from two unipolar TRD cohorts that received KET-IV (n = 171) at the Canadian Rapid Treatment Center of Excellence in Toronto, Canada, or ESK-NS (n = 140) at several TRD clinics in Italy. The Quick Inventory for Depression Symptomatology-Self-Report-16/QIDS-SR16 in the KET-IV group and Montgomery-Åsberg Depression Rating Scale/MADRS in the ESK-NS group measured depressive symptoms at baseline (T0) and after the acute treatment phase (T1) (i.e., four infusions of KET-IV and eight administrations of ESK-NS). As different scales were used, the primary outcome was to compare the improvement in depression severity in the two cohorts by measuring effect sizes, response and remission rates. Finally, we compare side effects and discontinuation rates. RESULTS At T1, KET-IV and ESK-NS significantly reduced depressive symptoms (respectively: QIDS-SR16 mean reduction = 5.65, p < 0.001; MADRS mean reduction = 11.41, p = 0.025). KET-IV showed larger effect sizes compared to ESK-NS (1.666 vs. 1.244). KET-IV had higher response rates (36 % vs. 25 %; p = 0.042) but not superior remission rates (13 % vs. 12 %; p = 0.845) than ESK-NS at T1. Despite more reported side effects, KET-IV did not cause more discontinuations for adverse events (4.6 % vs. 2.12 %; p = 0.228) than ESK-NS. CONCLUSION KET-IV showed a higher short-term antidepressant effect, whereas ESK-NS exhibited lower side effects. Both were generally well tolerated. Future head-to-head studies should consider the long-term efficacy of these treatments.
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Affiliation(s)
- Giacomo d'Andrea
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Mauro Pettorruso
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Giorgio Di Lorenzo
- Chair of Psychiatry, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy; IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, CT, USA; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington, CT, USA
| | - Stefania Chiappini
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Rosalba Carullo
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Raffaella Zanardi
- Mood Disorder Unit, Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Clinical Neurosciences, University Vita-Salute San Raffaele, Milan, Italy
| | - Gianluca Rosso
- Department of Neurosciences Rita Levi Montalcini, University of Torino, Turin, Italy
| | - Marco Di Nicola
- Department of Neurosciences, Section of Psychiatry, Università Cattolica del Sacro Cuore, Rome; Department of Psychiatry, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | | | - Matteo Marcatili
- Department of Mental Health and Addiction, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Massimo Clerici
- Department of Mental Health and Addiction, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Bernardo Maria Dell'Osso
- Department of Biomedical and Clinical Sciences Luigi Sacco and Aldo Ravelli Center for Neurotechnology and Brain Therapeutic, University of Milan, Milano, Italy
| | - Stefano L Sensi
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Rodrigo B Mansur
- 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
| | - Joshua D 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; Braxia Health, Canadian Centre for Rapid Treatment Excellence (CRTCE), Mississauga, ON, Canada
| | - Giovanni Martinotti
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy; Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK
| | - Roger S McIntyre
- 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; Braxia Health, Canadian Centre for Rapid Treatment Excellence (CRTCE), Mississauga, ON, Canada.
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Hashimoto K. Are "mystical experiences" essential for antidepressant actions of ketamine and the classic psychedelics? Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01770-7. [PMID: 38411629 DOI: 10.1007/s00406-024-01770-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/22/2024] [Indexed: 02/28/2024]
Abstract
The growing interest in the rapid and sustained antidepressant effects of the dissociative anesthetic ketamine and classic psychedelics, such as psilocybin, is remarkable. However, both ketamine and psychedelics are known to induce acute mystical experiences; ketamine can cause dissociative symptoms such as out-of-body experience, while psychedelics typically bring about hallucinogenic experiences, like a profound sense of unity with the universe or nature. The role of these mystical experiences in enhancing the antidepressant outcomes for patients with depression is currently an area of ongoing investigation and debate. Clinical studies have shown that the dissociative symptoms following the administration of ketamine or (S)-ketamine (esketamine) are not directly linked to their antidepressant properties. In contrast, the antidepressant potential of (R)-ketamine (arketamine), thought to lack dissociative side effects, has yet to be conclusively proven in large-scale clinical trials. Moreover, although the activation of the serotonin 5-HT2A receptor is crucial for the hallucinogenic effects of psychedelics in humans, its precise role in their antidepressant action is still under discussion. This article explores the importance of mystical experiences in enhancing the antidepressant efficacy of both ketamine and classic psychedelics.
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Affiliation(s)
- Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, 1-8-1 Inohana, Chiba, 260-8670, Japan.
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Yrondi A, Javelot H, Nobile B, Boudieu L, Aouizerate B, Llorca PM, Charpeaud T, Bennabi D, Lefrere A, Samalin L. French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN) guidelines for the management of patients with partially responsive depression and treatment-resistant depression: Update 2024. L'ENCEPHALE 2024:S0013-7006(24)00019-8. [PMID: 38369426 DOI: 10.1016/j.encep.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 02/20/2024]
Abstract
INTRODUCTION The purpose of this update is to add newly approved nomenclatures and treatments as well as treatments yet to be approved in major depressive disorder, thus expanding the discussions on the integration of resistance factors into the clinical approach. METHODS Unlike the first consensus guidelines based on the RAND/UCLA Appropriateness Method, the French Association for Biological Psychiatry and Neuropsychopharmacology (AFPBN) developed an update of these guidelines for the management of partially responsive depression (PRD) and treatment-resistant depression (TRD). The expert guidelines combine scientific evidence and expert clinicians' opinions to produce recommendations for PRD and TRD. RESULTS The recommendations addressed three areas judged as essential for updating the previous 2019 AFPBN guidelines for the management of patients with TRD: (1) the identification of risk factors associated with TRD, (2) the therapeutic management of patients with PRD and TRD, and (3) the indications, the modalities of use and the monitoring of recent glutamate receptor modulating agents (esketamine and ketamine). CONCLUSION These consensus-based guidelines make it possible to build bridges between the available empirical literature and clinical practice, with a highlight on the 'real world' of the clinical practice, supported by a pragmatic approach centred on the experience of specialised prescribers in TRD.
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Affiliation(s)
- Antoine Yrondi
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Fondation FondaMental, Créteil, France; Inserm, UPS, ToNIC, service de psychiatrie et psychologie médicale, Centre expert dépression résistante, Toulouse NeuroImaging Center, université de Toulouse, CHU de Toulouse, Toulouse, France
| | - Hervé Javelot
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; EPSAN, Centre de Ressources et d'Expertise en PsychoPharmacologie du Grand'Est (CREPP GE), Brumath, France; UR7296, laboratoire de pharmacologie, faculté de médecine de Strasbourg, Centre de recherche en biomédecine de Strasbourg (CRBS), Strasbourg, France
| | - Bénédicte Nobile
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Fondation FondaMental, Créteil, France; Department of Emergency Psychiatry and Acute Care, CHU de Montpellier, Montpellier, France; Inserm, CNRS, IGF, University of Montpellier, Montpellier, France
| | - Ludivine Boudieu
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Department of Psychiatry, CHU of Clermont-Ferrand, University of Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal (UMR 6602), Clermont-Ferrand, France
| | - Bruno Aouizerate
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Fondation FondaMental, Créteil, France; Centre hospitalier Charles-Perrens, université de Bordeaux, Bordeaux, France; Inrae, NutriNeuro, U1286, University of Bordeaux, Bordeaux, France
| | - Pierre-Michel Llorca
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Fondation FondaMental, Créteil, France; Department of Psychiatry, CHU of Clermont-Ferrand, University of Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal (UMR 6602), Clermont-Ferrand, France
| | - Thomas Charpeaud
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Clinique du Grand Pré, Durtol, France
| | - Djamila Bennabi
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Fondation FondaMental, Créteil, France; Centre d'investigation clinique, CIC-Inserm-1431, centre hospitalier universitaire de Besançon, Besançon, France
| | - Antoine Lefrere
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Fondation FondaMental, Créteil, France; UMR7289, CNRS, pôle de psychiatrie, institut de neurosciences de la Timone, Aix-Marseille université Assistance publique-Hôpitaux de Marseille, Marseille, France
| | - Ludovic Samalin
- French Society for Biological Psychiatry and Neuropsychopharmacology (AFPBN), Saint-Germain-en-Laye, France; Fondation FondaMental, Créteil, France; Department of Psychiatry, CHU of Clermont-Ferrand, University of Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal (UMR 6602), Clermont-Ferrand, France.
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Jollant F, Demattei C, Fabbro P, Abbar M. Clinical predictive factors and trajectories of suicidal remission over 6 weeks following intravenous ketamine for suicidal ideation. J Affect Disord 2024; 347:1-7. [PMID: 37981038 DOI: 10.1016/j.jad.2023.11.043] [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: 08/08/2023] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Ketamine is efficient for short-term reduction of suicidal ideas. Predictive factors and outcome trajectories are poorly characterized. METHODS Secondary analyses were conducted on the KETIS study (Abbar et al. BMJ 2022): 156 suicidal patients were randomized to two intravenous infusions of racemic ketamine (0.5 mg/kg) or placebo. Response or remission was assessed over six weeks based on the Beck Scale for Suicidal Ideation (SSI). We calculated i) predictive values of 12 baseline variables on remission ii) outcome courses, and iii) positive (PPV) and negative predictive values. RESULTS In multivariate analyses, bipolar disorder, lower patient-rated suicidal ideas, and higher physical pain were predictive of suicidal remission at day 3. No clinical factor predicted remission at week 6. Twenty and 24 different clinical courses were identified in early (day 3) and later (week 6) follow-up, respectively, including around 40 % sustained remission, 50 % fluctuating course and 10 % no response. Suicidal remissions at day 1 and day 3 were highly predictive of remissions at day 3 and week 6 (PPV = 96.8 and 92.6 %). LIMITATIONS SSI may not be adapted for rapid variations and repeated measures. CONCLUSIONS Clinical factors were poorly predictive of remission. Fluctuations in suicidal ideas were frequent, even after ketamine (although less than placebo), necessitating vigilance and multimodal care. Remission at day 1 after one infusion was highly predictive of future remission. The benefits of a second infusion will have to be tested.
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Affiliation(s)
- Fabrice Jollant
- Department of Psychiatry, CHU Nîmes, Univ Montpellier, Nîmes, France; Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, France; Department of Psychiatry, Bicêtre Hospital, AP-HP, Le Kremlin Bicêtre, France; Moods Research Team, Inserm 1018, CESP, Le Kremlin-Bicêtre, France; Department of Psychiatry, McGill Group for Suicide Studies, McGill University, Montreal, Canada.
| | - Christophe Demattei
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM) CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Pascale Fabbro
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology (BESPIM) CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Mocrane Abbar
- Department of Psychiatry, CHU Nîmes, Univ Montpellier, Nîmes, France
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Niciu MJ, Meisner RC, Carr BR, Farooqui AA, Feifel D, Kaplin A, Kendrick EJ, Kim PM, Schneck CD, Vande Voort JL, Parikh SV. National Network of Depression Centers position statement: Insurance coverage for intravenous ketamine in treatment-resistant major depressive disorder. J Affect Disord 2024; 346:221-222. [PMID: 37940059 DOI: 10.1016/j.jad.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/01/2023] [Accepted: 11/03/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Mark J Niciu
- University of Iowa Health Care, Department of Psychiatry/Iowa Neuroscience Institute, Iowa City, IA 52242, USA.
| | - Robert C Meisner
- McLean Hospital, Psychiatric Neurotherapeutics Program, 115 Mill St., Belmont, MA 02478, USA; Harvard Medical School, Department of Psychiatry, Boston, MA 02115, USA
| | - Brent R Carr
- University of Florida College of Medicine, Department of Psychiatry, Gainesville, FL 32610, USA
| | - Ali A Farooqui
- University of Louisville School of Medicine, Department of Psychiatry and Behavioral Sciences, Louisville, KY 40202, USA
| | - David Feifel
- Kadima Neuropsychiatry Institute, La Jolla, CA 92037, USA; University of California San Diego School of Medicine, La Jolla, CA 92093, USA
| | - Adam Kaplin
- Mira Pharmaceuticals, Baltimore, MD 21205, USA; The Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD 21205, USA
| | - E Jeremy Kendrick
- University of Utah School of Medicine, Department of Psychiatry, University Neuropsychiatric Institute, Salt Lake City, UT 84132, USA
| | - Paul M Kim
- The Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD 21205, USA
| | - Christopher D Schneck
- University of Colorado Anschutz Medical Campus, Department of Psychiatry, Helen and Arthur E. Johnson Depression Center, Aurora, CO 80045, USA
| | | | - Sagar V Parikh
- University of Michigan School of Medicine, Department of Psychiatry and Depression Center, Ann Arbor, MI 48109, USA
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Duan WY, Peng K, Qin HM, Li BM, Xu YX, Wang DJ, Yu L, Wang H, Hu J, Wang QX. Esketamine accelerates emergence from isoflurane general anaesthesia by activating the paraventricular thalamus glutamatergic neurones in mice. Br J Anaesth 2024; 132:334-342. [PMID: 38044237 DOI: 10.1016/j.bja.2023.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/02/2023] [Accepted: 10/18/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Delayed emergence from general anaesthesia poses a significant perioperative safety hazard. Subanaesthetic doses of ketamine not only deepen anaesthesia but also accelerate recovery from isoflurane anaesthesia; however, the mechanisms underlying this phenomenon remain elusive. Esketamine exhibits a more potent receptor affinity and fewer adverse effects than ketamine and exhibits shorter recovery times after brief periods of anaesthesia. As the paraventricular thalamus (PVT) plays a pivotal role in regulating wakefulness, we studied its role in the emergence process during combined esketamine and isoflurane anaesthesia. METHODS The righting reflex and cortical electroencephalography were used as measures of consciousness in mice during isoflurane anaesthesia with coadministration of esketamine. The expression of c-Fos was used to determine neuronal activity changes in PVT neurones after esketamine administration. The effect of esketamine combined with isoflurane anaesthesia on PVT glutamatergic (PVTGlu) neuronal activity was monitored by fibre photometry, and chemogenetic technology was used to manipulate PVTGlu neuronal activity. RESULTS A low dose of esketamine (5 mg kg-1) accelerated emergence from isoflurane general anaesthesia (474 [30] s vs 544 [39] s, P=0.001). Esketamine (5 mg kg-1) increased PVT c-Fos expression (508 [198] vs 258 [87], P=0.009) and enhanced the population activity of PVTGlu neurones (0.03 [1.7]% vs 6.9 [3.4]%, P=0.002) during isoflurane anaesthesia (1.9 [5.7]% vs -5.1 [5.3]%, P=0.016) and emergence (6.1 [6.2]% vs -1.1 [5.0]%, P=0.022). Chemogenetic suppression of PVTGlu neurones abolished the arousal-promoting effects of esketamine (459 [33] s vs 596 [33] s, P<0.001). CONCLUSIONS Our results suggest that esketamine promotes recovery from isoflurane anaesthesia by activating PVTGlu neurones. This mechanism could explain the rapid arousability exhibited upon treatment with a low dose of esketamine.
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Affiliation(s)
- Wen-Ying Duan
- Department of Anesthesiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Kang Peng
- School of Life Science and Technology, ShanghaiTech University, Shanghai, China; Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Hui-Min Qin
- School of Life Science and Technology, ShanghaiTech University, Shanghai, China
| | - Bai-Ming Li
- Department of Anesthesiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yun-Xin Xu
- Department of Anesthesiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dan-Jun Wang
- Department of Anesthesiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Le Yu
- Department of Anesthesiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hui Wang
- Department of Anesthesiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ji Hu
- School of Life Science and Technology, ShanghaiTech University, Shanghai, China.
| | - Qing-Xiu Wang
- Department of Anesthesiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.
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Rodgers A, Bahceci D, Davey CG, Chatterton ML, Glozier N, Hopwood M, Loo C. Ensuring the affordable becomes accessible-lessons from ketamine, a new treatment for severe depression. Aust N Z J Psychiatry 2024; 58:109-116. [PMID: 37830221 DOI: 10.1177/00048674231203898] [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] [Indexed: 10/14/2023]
Abstract
In this paper, the case study of ketamine as a new treatment for severe depression is used to outline the challenges of repurposing established medicines and we suggest potential solutions. The antidepressant effects of generic racemic ketamine were identified over 20 years ago, but there were insufficient incentives for commercial entities to pursue its registration, or support for non-commercial entities to fill this gap. As a result, the evaluation of generic ketamine was delayed, piecemeal, uncoordinated, and insufficient to gain approval. Meanwhile, substantial commercial investment enabled the widespread registration of a patented, intranasal s-enantiomeric ketamine formulation (Spravato®) for depression. However, Spravato is priced at $600-$900/dose compared to ~$5/dose for generic ketamine, and the ~AUD$100 million annual government investment requested in Australia (to cover drug costs alone) has been rejected twice, leaving this treatment largely inaccessible for Australian patients 2 years after Therapeutic Goods Administration approval. Moreover, emerging evidence indicates that generic racemic ketamine is at least as effective as Spravato, but no comparative trials were required for regulatory approval and have not been conducted. Without action, this story will repeat regularly in the next decade with a new wave of psychedelic-assisted psychotherapy treatments, for which the original off-patent molecules could be available at low-cost and reduce the overall cost of treatment. Several systemic reforms are required to ensure that affordable, effective options become accessible; these include commercial incentives, public and public-private funding schemes, reduced regulatory barriers and more coordinated international public funding schemes to support translational research.
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Affiliation(s)
- Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Dilara Bahceci
- The George Institute for Global Health, University of New South Wales, Newtown, NSW, Australia
| | - Christopher G Davey
- Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Mary Lou Chatterton
- Health Economics Group, Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Nick Glozier
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Colleen Loo
- School of Psychiatry, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
- Black Dog Institute, Randwick, NSW, Australia
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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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Wang J, Feng Y, Qi Z, Li J, Chen Z, Zhang J, Zhu D. The role and mechanism of esketamine in preventing and treating remifentanil-induced hyperalgesia based on the NMDA receptor-CaMKII pathway. Open Life Sci 2024; 19:20220816. [PMID: 38314140 PMCID: PMC10836417 DOI: 10.1515/biol-2022-0816] [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: 09/17/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 02/06/2024] Open
Abstract
Remifentanil-induced hyperalgesia (RIH) is a common clinical phenomenon that limits the use of opioids in pain management. Esketamine, a non-competitive N-methyl-d-aspartate (NMDA) receptor antagonist, has been shown to prevent and treat RIH. However, the underlying effect mechanism of esketamine on RIH remains unclear. This study aimed to investigate the role and mechanism of esketamine in preventing and treating RIH based on the NMDA receptor-CaMKIIα pathway. In this study, an experimental animal model was used to determine the therapeutic effect of esketamine on pain elimination. Moreover, the mRNA transcription and protein expression levels of CaMKII and GluN2B were investigated to offer evidence of the protective capability of esketamine in ameliorating RIH. The results demonstrated that esketamine attenuated RIH by inhibiting CaMKII phosphorylation and downstream signaling pathways mediated by the NMDA receptor. Furthermore, ketamine reversed the upregulation of spinal CaMKII induced by remifentanil. These findings suggest that the NMDA receptor-CaMKII pathway plays a critical role in the development of RIH, and ketamine's effect on this pathway may provide a new therapeutic approach for the prevention and treatment of RIH.
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Affiliation(s)
- Jiafang Wang
- Department of Anesthesiology, Wuhan No. 1 Hospital, No. 215 Zhongshan Avenue, Qiaokou District, Wuhan, Hubei, 430022, China
| | - Yankun Feng
- Department of Anesthesiology, Wuhan No. 1 Hospital, No. 215 Zhongshan Avenue, Qiaokou District, Wuhan, Hubei, 430022, China
| | - Zhong Qi
- Department of Anesthesiology, Wuhan No. 1 Hospital, No. 215 Zhongshan Avenue, Qiaokou District, Wuhan, Hubei, 430022, China
| | - Jin Li
- Department of Anesthesiology, Wuhan No. 1 Hospital, No. 215 Zhongshan Avenue, Qiaokou District, Wuhan, Hubei, 430022, China
| | - Zhijun Chen
- Department of Anesthesiology, Wuhan No. 1 Hospital, No. 215 Zhongshan Avenue, Qiaokou District, Wuhan, Hubei, 430022, China
| | - Jinming Zhang
- Hubei Provincial Key Laboratory for Applied Toxicology, Hubei Center for Disease Control and Prevention, No. 35 Zhuodaoquan North Road, Hongshan District, Wuhan 430079, China
| | - Degang Zhu
- Department of Anesthesiology, Wuhan No. 1 Hospital, No. 215 Zhongshan Avenue, Qiaokou District, Wuhan, Hubei, 430022, China
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Ip CT, de Bardeci M, Kronenberg G, Pinborg LH, Seifritz E, Brunovsky M, Olbrich S. EEG-vigilance regulation is associated with and predicts ketamine response in major depressive disorder. Transl Psychiatry 2024; 14:64. [PMID: 38272875 PMCID: PMC10810879 DOI: 10.1038/s41398-024-02761-x] [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] [Received: 05/04/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 01/27/2024] Open
Abstract
Ketamine offers promising new therapeutic options for difficult-to-treat depression. The efficacy of treatment response, including ketamine, has been intricately linked to EEG measures of vigilance. This research investigated the interplay between intravenous ketamine and alterations in brain arousal, quantified through EEG vigilance assessments in two distinct cohorts of depressed patients (original dataset: n = 24; testing dataset: n = 24). Clinical response was defined as a decrease from baseline of >33% on the Montgomery-Åsberg Depression Rating Scale (MADRS) 24 h after infusion. EEG recordings were obtained pre-, start-, end- and 24 h post- infusion, and the resting EEG was automatically scored using the Vigilance Algorithm Leipzig (VIGALL). Relative to placebo (sodium chloride 0.9%), ketamine increased the amount of low-vigilance stage B1 at end-infusion. This increase in B1 was positively related to serum concentrations of ketamine, but not to norketamine, and was independent of clinical response. In contrast, treatment responders showed a distinct EEG pattern characterized by a decrease in high-vigilance stage A1 and an increase in low-vigilance B2/3, regardless of whether placebo or ketamine had been given. Furthermore, pretreatment EEG differed between responders and non-responders with responders showing a higher percentage of stage A1 (53% vs. 21%). The logistic regression fitted on the percent of A1 stages was able to predict treatment outcomes in the testing dataset with an area under the ROC curve of 0.7. Ketamine affects EEG vigilance in a distinct pattern observed only in responders. Consequently, the percentage of pretreatment stage A1 shows significant potential as a predictive biomarker of treatment response.Clinical Trials Registration: https://www.clinicaltrialsregister.eu/ctr-search/trial/2013-000952-17/CZ Registration number: EudraCT Number: 2013-000952-17.
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Affiliation(s)
- Cheng-Teng Ip
- Center for Cognitive and Brain Sciences, University of Macau, Taipa, Macau SAR, China
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mateo de Bardeci
- Hospital for Psychiatry, Psychotherapy and Psychosomatic; University Zurich, Zurich, Switzerland
| | - Golo Kronenberg
- Hospital for Psychiatry, Psychotherapy and Psychosomatic; University Zurich, Zurich, Switzerland
| | - Lars Hageman Pinborg
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark
- Epilepsy Clinic, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Erich Seifritz
- Hospital for Psychiatry, Psychotherapy and Psychosomatic; University Zurich, Zurich, Switzerland
| | - Martin Brunovsky
- National Institute of Mental Health, Klecany, Czech Republic
- Charles University, Third Faculty of Medicine, Prague, Czech Republic
| | - Sebastian Olbrich
- Hospital for Psychiatry, Psychotherapy and Psychosomatic; University Zurich, Zurich, Switzerland.
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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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Wang W, Ling B, Zhao H, He J, Xu H, Lv J, Wang Q. Effect of esketamine on postpartum depression after labor analgesia and potential mechanisms: a randomized, double-blinded controlled trial. BMC Anesthesiol 2024; 24:4. [PMID: 38166663 PMCID: PMC10759400 DOI: 10.1186/s12871-023-02377-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND To evaluate the effect of esketamine combined with ropivacaine hydrochloride on the occurrence of postpartum depression (PPD) after labor analgesia under epidural analgesia pump and explore the possible mechanisms. METHODS A total of 120 women aged 24 to 36 years old who underwent labor analgesia by epidural analgesia pump, with American Society of Anesthesiologists (ASA) physical status II were enrolled. According to the formula of epidural analgesia pump, all participants were randomly divided into two groups: esketamine group (Group E) and control group (Group C). Epidural anaesthesia were operated in all women between L2 and L3 after cervical dilation up to 2 ~ 3 cm. After successful puncture, the epidural catheter was placed 3.5 cm toward the head and 1% lidocaine was injected for 3 ml. The epidural analgesia pump was connected. Esketamine (0.2 mg/kg) combined with 0.75% ropivacaine hydrochloride (20 ml) were diluted by normal saline up to 100 ml in Group E, when only the equal dose of ropivacaine hydrochloride was used in Group C. The visual analogue scale (VAS) before analgesia (T1), 5 (T2), 10 (T3) and 20 (T4) minutes after analgesia were measured. The duration of the first and second stage of labor, the Apgar score of fetus at delivery, postpartum hemorrhage, consumption of esketamine and ropivacaine were recorded. The incidence of PPD was recorded at 1 week and 6 weeks after delivering. The occurrence of side effects such as nausea and vomiting, dizziness, and nightmares were also recorded for 48 h after delivering. The levels of leptin, norepinephrine(NE), and epinephrine(E) in the peripheral venous blood were measured before labor analgesia and at 24 h, 1 week, and 6 weeks after delivering. RESULTS Compared with Group C, the VAS score at T2, T3 and T4 were significantly lower in Group E (P < 0.01). Compared with Group C, the incidence of PPD was significantly lower at 1 week and 6 weeks after delivering in Group E (P < 0.01). Compared with Group C, the levels of leptin were significantly higher at 24 h and 1 week after delivering in Group E (P < 0.01), while NE and E (P < 0.01) were lower at the same time (P < 0.01). There were no significant difference of the duration of the first and second stage of labor, the Apgar score of fetus at delivery, postpartum hemorrhage, consumption of ropivacaine and the side effects for 48 h after delivering between the two groups. CONCLUSION Esketamine combined with ropivacaine hydrochloride used in labor analgesia can significantly reduce the incidence of postpartum depression after delivering without increasing related side effects, which may be related to the regulation of leptin, norepinephrine, and epinephrine in the serum. TRIAL REGISTRATION The trial was registered at the Chinese Clinical Trial Registry on 30/05/2022 (CTRI registration number-ChiCTR2200060387). URL of registry: https://www.chictr.org.cn/bin/home .
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Affiliation(s)
- Wei Wang
- Department of Anesthesiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 169 Hushan Road, Nanjing, 211100, China
| | - Bin Ling
- Department of Anesthesiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 169 Hushan Road, Nanjing, 211100, China
| | - Haibo Zhao
- Department of Anesthesiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 169 Hushan Road, Nanjing, 211100, China
| | - Jing He
- Department of Anesthesiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 169 Hushan Road, Nanjing, 211100, China
| | - Hua Xu
- Department of Gynaecology and obstetrics, The Affiliated Jiangning Hospital of Nanjing Medical University, Nangjing, 211100, China
| | - Jie Lv
- Department of Anesthesiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 169 Hushan Road, Nanjing, 211100, China
| | - Qi Wang
- Department of Anesthesiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 169 Hushan Road, Nanjing, 211100, China.
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Chang M, Juruena MF, Young AH. Ketamine cystitis following ketamine therapy for treatment-resistant depression - case report. BMC Psychiatry 2024; 24:9. [PMID: 38166893 PMCID: PMC10763323 DOI: 10.1186/s12888-023-05468-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Ketamine is a novel and exciting putative antidepressant medication for patients with treatment-resistant depression. A complication commonly seen in frequent and heavy recreational use of ketamine is ulcerative cystitis, which presents with lower urinary tract symptoms (LUTS) and upper renal tract damage and can be seen in over 25% of regular users. Although Ketamine-induced cystitis (KIC) is a recognised complication in recreational use of ketamine, its occurrence in therapeutic use of ketamine in depression has so far not been reported. The exact pathogenesis of KIC is currently unknown, making treatment and prevention advice much more difficult. Early diagnosis of KIC and immediate cessation of ketamine has been shown to improve adverse urinary tract symptoms and prevent further damage. CASE PRESENTATION We present a case of a 28-year-old female who was started on ketamine treatment for depression, and who then developed symptoms of KIC, which was confirmed by urine microscopy, culture and analysis. CONCLUSIONS To our knowledge, this is the first reported case of KIC in a patient receiving treatment-dose ketamine as part of their antidepressant therapy.
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Affiliation(s)
- Minna Chang
- Epsom and St Helier Hospital University and Hospital Trust, Epsom Surrey, KT18 7EG, UK.
| | - Mario F Juruena
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley (SLaM) NHS Foundation Trust, London, UK
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley (SLaM) NHS Foundation Trust, London, UK
- Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK
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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: 8] [Impact Index Per Article: 8.0] [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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Krystal JH, Kavalali ET, Monteggia LM. Ketamine and rapid antidepressant action: new treatments and novel synaptic signaling mechanisms. Neuropsychopharmacology 2024; 49:41-50. [PMID: 37488280 PMCID: PMC10700627 DOI: 10.1038/s41386-023-01629-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/29/2023] [Accepted: 06/04/2023] [Indexed: 07/26/2023]
Abstract
Ketamine is an open channel blocker of ionotropic glutamatergic N-Methyl-D-Aspartate (NMDA) receptors. The discovery of its rapid antidepressant effects in patients with depression and treatment-resistant depression fostered novel effective treatments for mood disorders. This discovery not only provided new insight into the neurobiology of mood disorders but also uncovered fundamental synaptic plasticity mechanisms that underlie its treatment. In this review, we discuss key clinical aspects of ketamine's effect as a rapidly acting antidepressant, synaptic and circuit mechanisms underlying its action, as well as how these novel perspectives in clinical practice and synapse biology form a road map for future studies aimed at more effective treatments for neuropsychiatric disorders.
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Affiliation(s)
- John H Krystal
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Ege T Kavalali
- Department of Pharmacology and the Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA
| | - Lisa M Monteggia
- Department of Pharmacology and the Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA.
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Savić Vujović K, Jotić A, Medić B, Srebro D, Vujović A, Žujović J, Opanković A, Vučković S. Ketamine, an Old-New Drug: Uses and Abuses. Pharmaceuticals (Basel) 2023; 17:16. [PMID: 38276001 PMCID: PMC10820504 DOI: 10.3390/ph17010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 01/27/2024] Open
Abstract
Ketamine as an old-new drug has a variety of clinical implications. In the last 30 years, ketamine has become popular for acute use in humans. Ketamine in standard doses is principally utilized for the induction and maintenance of surgical procedures. Besides its use in anesthesia and analgesia, recent studies have shown that ketamine has found a place in the treatment of asthma, epilepsy, depression, bipolar affective disorders, alcohol and heroin addiction. Ketamine primarily functions as a noncompetitive antagonist targeting the N-methyl-D-aspartate (NMDA) receptor, but its mechanism of action is complex. It is generally regarded as safe, with low doses and short-term use typically not leading to significant adverse effects. Also, ketamine is known as a powerful psychostimulant. During the past decade, ketamine has been one of the commonly abused drugs.
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Affiliation(s)
- Katarina Savić Vujović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | - Ana Jotić
- Clinic for Otorhinolaryngology and Maxillofacial Surgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia;
| | - Branislava Medić
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | - Dragana Srebro
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | | | - Janko Žujović
- Clinical Centre of Montenegro, Centre for Abdominal Surgery, 81000 Podgorica, Montenegro;
| | - Ana Opanković
- Clinical Centre of Serbia, Clinic for Psychiatry, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Sonja Vučković
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
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Jiang Y, Du Z, Shen Y, Zhou Q, Zhu H. The correlation of Esketamine with specific adverse events: a deep dive into the FAERS database. Eur Arch Psychiatry Clin Neurosci 2023:10.1007/s00406-023-01732-5. [PMID: 38103077 DOI: 10.1007/s00406-023-01732-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
Analyzing the vast data from FAERS database to evaluate the association between Esketamine and specific adverse events to guide clinical practice and regulatory decisions. Data related to Esketamine adverse events from 2019 Q1 to 2023 Q1 were collected from FAERS database. After data standardization, various signal quantification technologies, such as ROR, PRR, BCPNN, and MGPS, were employed to identify and evaluate adverse reaction signals closely related to the use of Esketamine comprehensively. A total of 5061 reports with Esketamine as the primary suspected drug were obtained, identifying 117 adverse reaction terms (PT) involving 27 system organ class (SOC) categories. Apart from the adverse events already mentioned in the drug's instructions, this study identified some new, clinically valuable potential AE signals, such as Flashback, Tachyphylaxis, and Autoscopy. In addition, high-ranking results included euphoric mood, feeling of relaxation, and feeling drunk. Notably, the occurrence frequencies of suicidal ideation and suicide attempt were relatively high, so clinicians should be particularly vigilant about these potential adverse reactions when using Esketamine. Moreover, since this drug is administered as a nasal spray, issues such as drug monitoring procedure incorrectly performed and nasal discomfort may arise. This study underscores the potential adverse reactions and risks of Esketamine in clinical applications, especially regarding long-term efficacy, addiction risks, and suicidal risks.
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Affiliation(s)
- Ying Jiang
- Mental Health Center of Jiangnan University, Wuxi Central Rehabilitation Hospital, Wuxi, 214151, Jiangsu, China
| | - Zhiqiang Du
- Mental Health Center of Jiangnan University, Wuxi Central Rehabilitation Hospital, Wuxi, 214151, Jiangsu, China
| | - Yuan Shen
- Mental Health Center of Jiangnan University, Wuxi Central Rehabilitation Hospital, Wuxi, 214151, Jiangsu, China
| | - Qin Zhou
- Mental Health Center of Jiangnan University, Wuxi Central Rehabilitation Hospital, Wuxi, 214151, Jiangsu, China
| | - Haohao Zhu
- Mental Health Center of Jiangnan University, Wuxi Central Rehabilitation Hospital, Wuxi, 214151, Jiangsu, China.
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Titone MK, Hunt C, Bismark A, Nokes B, Lee E, Ramanathan D, Park J, Colvonen P. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med 2023; 19:2043-2051. [PMID: 37539643 PMCID: PMC10692930 DOI: 10.5664/jcsm.10746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
STUDY OBJECTIVES Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression. METHODS Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories. RESULTS We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis. CONCLUSIONS Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD. CITATION Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.
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Affiliation(s)
- Madison K. Titone
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | | | | | - Brandon Nokes
- VA San Diego Healthcare System, San Diego, California
| | - Ellen Lee
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Dhakshin Ramanathan
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Jane Park
- VA San Diego Healthcare System, San Diego, California
| | - Peter Colvonen
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
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45
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Cottone JG. Ketamine-Assisted Psychodynamic Psychotherapy. Psychodyn Psychiatry 2023; 51:467-478. [PMID: 38047669 DOI: 10.1521/pdps.2023.51.4.467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
This case report details the treatment of a longtime psychodynamic psychotherapy patient, with a particular focus on a ketamine-assisted psychotherapy (KAP) session, and how the progress achieved during this session compares with the literature on KAP. The patient is a 54-year-old woman with a history of multiple traumas, including sexual assault and life-threatening physical injuries, as well as a recent diagnosis of primary lateral sclerosis (PLS). For most of her life, she relied on extreme idealization of important people in her life as her primary defense mechanism, helping her to maintain physical and psychological survival. However, after a KAP session in January 2023 she discovered the consequences of her extreme idealizing tendencies. Among these was the creation of troubling double binds for the people she idealized, as well as the fomentation of conflict between these individuals with each other. Also unconscious was the secondary gain offered by her escalating physical symptoms and pain-that is, the ability to resolve conflicts between those she idealized-and how this secondary gain increased the likelihood of symptom exacerbations during periods of conflict. After the discovery of these unconscious tendencies during her KAP session, the patient has since been able to avoid extreme idealization of important people in her life and has subsequently experienced fewer episodes of exacerbation of her physical symptoms. Consistent with the opinions of clinicians and researchers published in the literature, the achievement of a psychedelic trance state appeared necessary for the success of the patient's KAP treatment.
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46
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Dutton M, Can AT, Lagopoulos J, Hermens DF. Oral ketamine may offer a solution to the ketamine conundrum. Psychopharmacology (Berl) 2023; 240:2483-2497. [PMID: 37882811 PMCID: PMC10640543 DOI: 10.1007/s00213-023-06480-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023]
Abstract
Ketamine has received considerable attention for its rapid and robust antidepressant response over the past decade. Current evidence, in clinical populations, predominantly relates to parenterally administered ketamine, which is reported to produce significant undesirable side effects, with additional concerns regarding long-term safety and abuse potential. Attempts to produce a similar drug to ketamine, without the psychotomimetic side effects, have proved elusive. Orally administered ketamine has a different pharmacological profile to parentally administered ketamine, suggesting it may be a viable alternative. Emerging evidence regarding the efficacy and tolerability of oral ketamine suggests that it may be a favourable route of administration, as it appears to obtain similarly beneficial treatment effects, but without the cost and medical resources required in parenteral dosing. The pharmacological effects may be due to the active metabolite norketamine, which has been found to be at substantially higher levels via oral dosing, most likely due to first-pass clearance. Despite bioavailability and peak plasma concentrations both being lower than when administered parenterally, evidence suggests that low-dose oral ketamine is clinically effective in treating pain. This may also be due to the actions of norketamine and therefore, its relevance to the mental health context is explored in this narrative review.
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Affiliation(s)
- Megan Dutton
- Thompson Institute, University of the Sunshine Coast, 12 Innovation Parkway, Birtinya, QLD, 4575, Australia.
| | - Adem T Can
- Thompson Institute, University of the Sunshine Coast, 12 Innovation Parkway, Birtinya, QLD, 4575, Australia
| | - Jim Lagopoulos
- Thompson Institute, University of the Sunshine Coast, 12 Innovation Parkway, Birtinya, QLD, 4575, Australia
| | - Daniel F Hermens
- Thompson Institute, University of the Sunshine Coast, 12 Innovation Parkway, Birtinya, QLD, 4575, Australia
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Loo C, Glozier N, Barton D, Baune BT, Mills NT, Fitzgerald P, Glue P, Sarma S, Galvez-Ortiz V, Hadzi-Pavlovic D, Alonzo A, Dong V, Martin D, Nikolin S, Mitchell PB, Berk M, Carter G, Hackett M, Leyden J, Hood S, Somogyi AA, Lapidus K, Stratton E, Gainsford K, Garg D, Thornton NLR, Fourrier C, Richardson K, Rozakis D, Scaria A, Mihalopoulos C, Chatterton ML, McDonald WM, Boyce P, Holtzheimer PE, Kozel FA, Riva-Posse P, Rodgers A. Efficacy and safety of a 4-week course of repeated subcutaneous ketamine injections for treatment-resistant depression (KADS study): randomised double-blind active-controlled trial. Br J Psychiatry 2023; 223:533-541. [PMID: 38108319 PMCID: PMC10727911 DOI: 10.1192/bjp.2023.79] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Prior trials suggest that intravenous racemic ketamine is a highly effective for treatment-resistant depression (TRD), but phase 3 trials of racemic ketamine are needed. AIMS To assess the acute efficacy and safety of a 4-week course of subcutaneous racemic ketamine in participants with TRD. Trial registration: ACTRN12616001096448 at www.anzctr.org.au. METHOD This phase 3, double-blind, randomised, active-controlled multicentre trial was conducted at seven mood disorders centres in Australia and New Zealand. Participants received twice-weekly subcutaneous racemic ketamine or midazolam for 4 weeks. Initially, the trial tested fixed-dose ketamine 0.5 mg/kg versus midazolam 0.025 mg/kg (cohort 1). Dosing was revised, after a Data Safety Monitoring Board recommendation, to flexible-dose ketamine 0.5-0.9 mg/kg or midazolam 0.025-0.045 mg/kg, with response-guided dosing increments (cohort 2). The primary outcome was remission (Montgomery-Åsberg Rating Scale for Depression score ≤10) at the end of week 4. RESULTS The final analysis (those who received at least one treatment) comprised 68 in cohort 1 (fixed-dose), 106 in cohort 2 (flexible-dose). Ketamine was more efficacious than midazolam in cohort 2 (remission rate 19.6% v. 2.0%; OR = 12.1, 95% CI 2.1-69.2, P = 0.005), but not different in cohort 1 (remission rate 6.3% v. 8.8%; OR = 1.3, 95% CI 0.2-8.2, P = 0.76). Ketamine was well tolerated. Acute adverse effects (psychotomimetic, blood pressure increases) resolved within 2 h. CONCLUSIONS Adequately dosed subcutaneous racemic ketamine was efficacious and safe in treating TRD over a 4-week treatment period. The subcutaneous route is practical and feasible.
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Affiliation(s)
- Colleen Loo
- Black Dog Institute, University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Nick Glozier
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; and Australian Research Council Centre of Excellence for Children and Families over the Life Course, University of Sydney, Sydney, New South Wales, Australia
| | - David Barton
- Australian Centre for Heart Health, Royal Melbourne Hospital, North Melbourne, Victoria, Australia; and NeuroCentrix, South Carlton, Victoria, Australia
| | - Bernhard T. Baune
- Department of Psychiatry, University of Münster, Münster, Germany; Department of Psychiatry, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia; and Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Natalie T. Mills
- Discipline of Psychiatry, University of Adelaide, Adelaide, South Australia, Australia
| | - Paul Fitzgerald
- Australian National University School of Medicine and Psychology, Canberra, Australian Capital Territory, Australia
| | - Paul Glue
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Shanthi Sarma
- Mental Health and Specialist Services, Gold Coast Health, Bond University, Robina, Queensland, Australia
| | - Veronica Galvez-Ortiz
- Department of Psychiatry and Mental Health, Hospital Universitari Parc Tauli, Sabadell, Spain; and Institut Investigacio I Innovacio Parc Tauli, Sabadell, Spain
| | - Dusan Hadzi-Pavlovic
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Angelo Alonzo
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Vanessa Dong
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Donel Martin
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Stevan Nikolin
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia; University of New South Wales, Randwick, New South Wales, Australia; and George Institute for Global Health, Newtown, New South Wales, Australia
| | - Philip B. Mitchell
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Berk
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), School of Medicine, Barwon Health, Deakin University, Geelong, Australia
| | - Gregory Carter
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Maree Hackett
- George Institute for Global Health, Newtown, New South Wales, Australia
| | - John Leyden
- Royal North Shore Hospital, St Leonards, New South Wales, Australia; and Northern Sydney Anaesthetic Research Institute, St Leonards, New South Wales, Australia
| | - Sean Hood
- Division of Psychiatry, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew A. Somogyi
- Discipline of Pharmacology, School of Biomedicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Kyle Lapidus
- Affective Care, Northwell Health, New York, New York, USA
| | - Elizabeth Stratton
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten Gainsford
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Monash University, Camberwell, Victoria, Australia
| | - Deepak Garg
- Mental Health and Specialist Services, Gold Coast Health, Bond University, Robina, Queensland, Australia
| | - Nicollette L. R. Thornton
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; and Australian Research Council Centre of Excellence for Children and Families over the Life Course, University of Sydney, Sydney, New South Wales, Australia
| | - Célia Fourrier
- Discipline of Psychiatry, University of Adelaide, Adelaide, South Australia, Australia; and Lysosomal Health in Ageing, Hopwood Centre for Neurobiology, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Karyn Richardson
- BrainPark, Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia; and Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Monash University, Camberwell, Victoria, Australia
| | | | - Anish Scaria
- George Institute for Global Health, Newtown, New South Wales, Australia
| | - Cathrine Mihalopoulos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; and School of Health and Social Development, Deakin University, Geelong, Australia
| | - Mary Lou Chatterton
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - William M. McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Philip Boyce
- Specialty of Psychiatry, Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paul E. Holtzheimer
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA; and Department of Surgery, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - F. Andrew Kozel
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anthony Rodgers
- George Institute for Global Health, Newtown, New South Wales, Australia
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Guilloux JP, Nguyen TML, Gardier AM. [Ketamine: a neuropsychotropic drug with an innovative mechanism of action]. Biol Aujourdhui 2023; 217:133-144. [PMID: 38018940 DOI: 10.1051/jbio/2023026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Indexed: 11/30/2023]
Abstract
Ketamine, a non-competitive antagonist of the N-methyl-D-aspartate-glutamate receptor (R-NMDA), has a rapid (from 24 h post-dose) and prolonged (up to one week) antidepressant effect in treatment resistant depression and in rodent models of anxiety/depression. Arguments regarding its cellular and molecular mechanisms underlying its antidepressant activity mainly come from animal studies. However, debates still persist on the structural remodeling of frontocortical/hippocampal neurons and the role of excitatory/inhibitory neurotransmitters involved in its behavioral effect. Neurochemical and behavioral changes are maintained 24 h after administration of ketamine, well beyond its plasma elimination half-life. The glutamatergic pyramidal cells of the medial prefrontal cortex are primarily implicated in the therapeutic effects of ketamine. Advances in knowledge of the consequences of R-NMDA blockade allowed to specify the underlying mechanisms involving the activation of AMPA glutamate receptors, which triggers a cascade of intracellular events dependent on the mechanistic target of rapamycin, brain-derived neurotrophic factor, and synaptic protein synthesis facilitating synaptic plasticity (number of dendritic spines, synaptogenesis). This review focuses on abnormalities of neurotransmitter systems involved in major depressive disorders, their potential impact on neural circuitry and beneficial effects of ketamine. Recent preclinical data pave the way for future studies to better clarify the mechanism of action of fast-acting antidepressant drugs for the development of novel, more effective therapies.
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Affiliation(s)
- Jean-Philippe Guilloux
- Laboratoire de Neuropharmacologie, Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, Équipe MOODS, F-91400 Orsay, France
| | - Thi Mai Loan Nguyen
- Laboratoire de Neuropharmacologie, Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, Équipe MOODS, F-91400 Orsay, France
| | - Alain M Gardier
- Laboratoire de Neuropharmacologie, Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, Équipe MOODS, F-91400 Orsay, France
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Fossati P. [Ketamine in antidepressant treatment: a revolution?]. Biol Aujourdhui 2023; 217:151-154. [PMID: 38018942 DOI: 10.1051/jbio/2023023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Indexed: 11/30/2023]
Abstract
Thirty percent of depressed patients are treatment resistant (TRD) suggesting the need of new therapeutic strategy. Recently, it has been shown that ketamine, an anesthetic agent with dissociative effects, has potent and rapid antidepressant properties. Ketamine is a ionotropic glutamatergic NMDA antagonist that inhibits gabaergic neurons. Its antidepressant effect peaks at 24 h post-treatment. Several meta-analyses of placebo randomized clinical trials emphasized its efficacy. More recently, a meta-analysis showed its efficiency in real-world population of TRD patients. Although there is no clear biological or clinical predictors of response or remission to ketamine, patients with high level of resistance were found to remit less often. Restoring both the optimism bias and the asymmetry in belief updating mediates the antidepressant ketamine's effect. Consistent with predictive bayesian model and terror management theory, this suggests that dissociation induced by ketamine may contribute to its clinical antidepressant action. Although increasing access to ketamine and esketamine is welcome, legitimate concerns have been raised with respect to long-term safety and abuse risk.
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Affiliation(s)
- Philippe Fossati
- Équipe « Contrôle-Interoception-Attention », Institut du Cerveau (ICM), Sorbonne Université, INSERM, CNRS, AP-HP, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences, Paris, France - Service de Psychiatrie Adultes, GH de la Pitié Salpêtrière, 47-83 Bd de l'Hôpital, 75013 Paris, France
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Bahji A, Lunsky I, Gutierrez G, Vazquez G. Efficacy and Safety of Four Psychedelic-Assisted Therapies for Adults with Symptoms of Depression, Anxiety, and Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis. J Psychoactive Drugs 2023:1-16. [PMID: 37968944 DOI: 10.1080/02791072.2023.2278586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/29/2023] [Indexed: 11/17/2023]
Abstract
There has been a resurgence in psychedelic research for managing psychiatric conditions in recent years. This study aimed to present a comprehensive review of the current state of the field by applying a systematic search strategy for articles on the effectiveness and tolerability of four psychedelic-assisted therapies (psilocybin, lysergic acid diethylamide [LSD], 3,4-Methylenedioxymethamphetamine [MDMA], and ayahuasca) for adults with symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). Psychometric scores and adverse events were pooled using random-effects meta-analysis models with Hedges' g bias-corrected standardized mean differences (g) and rate ratios (RR) with 95% confidence intervals (CI). Bias evaluation followed PRISMA and Cochrane guidelines. Eighteen studies were identified, which suggested that psychedelic therapies were well tolerated and presented a large effect size for the management of depression symptoms in a transdiagnostic population with psilocybin (g = -1.92, 95% CI, -2.73 to -1.11) and MDMA (g = -0.71; 95% CI, -1.39 to -0.03). These are promising results that complement the current literature. However, evidence certainty was low to very low due to methodological limitations, small sample size, blinding, study heterogeneity, and publication bias. These results also highlight the need for more adequately powered studies exploring these novel therapies.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Isis Lunsky
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Gilmar Gutierrez
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Gustavo Vazquez
- School of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
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