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

Treatment Options for Psychotic Depression in Adolescents: A Comprehensive Review

Despite being associated with increased illness severity and suicidality compared to non-psychotic depression, psychotic depression remains under-researched, particularly in adolescents. With this article, we aim to review treatment options for psychotic depression in adolescents. We performed a multi-step narrative review, first identifying studies on adolescents with psychotic depression evaluating any intervention and with any methodological design. We subsequently complemented our search with systematic reviews and meta-analysis evaluating treatment interventions in adults with psychotic depression and adolescents with bipolar depression. Finally, we reviewed clinical guidelines to complement the evidence found and provided recommendations for clinical practice. Based on the findings, we recommend a stepped approach to the treatment of psychotic depression in adolescents. For mild cases with predominance of depressive symptoms, antidepressant monotherapy with a serotonin selective reuptake inhibitor (eg fluoxetine, sertraline or citalopram) could be trialed first. In severe presentations, antidepressant-antipsychotic combination would be the treatment of choice. The antidepressant-antipsychotic combination has been recommended by several clinical guidelines, systematic reviews and meta-analysis in this population, adolescents with bipolar depression and adults with psychotic depression. Another combination of antidepressant-antipsychotic with evidence from a case report is the fluoxetine-quetiapine combination. For those adolescents not responding to the antidepressant-antipsychotic combination, or those requiring a rapid response or unable to take medication, electroconvulsive therapy could be considered. Psychological interventions (eg cognitive behavioral therapy, family therapy or interpersonal psychotherapy training for adolescents) are recommended by clinical guidelines but require further research. Overall, literature on the field is scarce and limited, with most evidence coming from adults and other populations. Further research into effective and safe treatment of psychotic depression in adolescent population is needed.

Comparative antidepressant effects and safety of intravenous racemic ketamine, psilocybin and theta burst stimulation for major depressive disorder: A systematic review and network meta-analyses of randomized controlled trials

The individual efficacy and safety of intravenous racemic (IV) ketamine, psilocybin, and theta burst stimulation (TBS) for major depressive disorder have been demonstrated through meta-analyses of randomized controlled trials (RCTs), but the comparative usefulness of these novel treatments has not yet been fully examined. We systematically searched the CENTRAL, Medline, CINHAL, and ClinicalTrials.gov databases for randomized controlled trials up to July 4, 2024. Random-effects network meta-analyses were conducted to compare the Comparative antidepressant effects and safety of intravenous racemic ketamine, psilocybin and theta burst stimulation for major depressive disorderantidepressant efficacy, tolerability, and acceptability of IV ketamine, psilocybin, and TBS. Twenty-eight RCTs were included. All treatments were superior to placebo, with IV ketamine and psilocybin showing significantly greater antidepressant efficacy than TBS. No significant differences were detected between all treatments and placebo in tolerability and acceptability. In a subgroup analysis focusing on short periods of 1 week or less, only IV ketamine was significantly more effective than placebo. In another subgroup analysis focusing on periods of 4 weeks or longer, IV ketamine and psilocybin showed significantly better antidepressant effects than placebo. The confidence in the evidence ranged from very low to moderate. Specifically, there is a scarcity of studies on psilocybin and a lack of direct comparison trials. The findings suggest that IV ketamine and psilocybin may be more effective treatments compared to TBS. Additionally, IV ketamine may have an advantage in terms of rapid onset of action. The number of included studies is limited, especially for psilocybin, and therefore the current findings are preliminary, necessitating further accumulation of direct-comparison RCTs.

Esketamine-Induced Dissociation: A Case Report

Esketamine, the isolated S-enantiomer of ketamine, has been a recent breakthrough as a non-monoaminergic treatment for treatment-resistant depression (TRD). This case report explores a rare adverse event in a 41-year-old female with TRD, who, despite experiencing significant depressive improvement with esketamine, encountered a severe dissociative episode accompanied by hallucinogenic-like phenomena. While esketamine's efficacy in TRD is well-documented, this pronounced dissociation should be taken into consideration by researchers and clinicians before prescribing. As esketamine continues to aid TRD treatment, comprehension of its safety profile becomes essential for informed decision-making, ensuring optimized patient care in the vast development of antidepressant therapies.

Esketamine Nasal Spray: Rapid Relief for TRD and Suicide Prevention-Mechanisms and Pharmacodynamics

Esketamine nasal spray has emerged as a promising rapid-relief therapy for treatment-resistant depression (TRD) and suicide prevention. This review examines the chemical structure and pharmacodynamics of esketamine, highlighting its primary action on NMDA receptors and additional effects on AMPA receptors, opioid receptors, monoaminergic receptors, and inflammatory pathways. Despite the synergistic mechanisms contributing to its clinical benefits not being fully understood, future studies are essential to refine our understanding and optimize clinical use. Clinical research indicates that esketamine effectively alleviates depressive symptoms and prevents suicidal behavior in TRD patients, demonstrating good safety and efficacy over extended periods. Specifically, multiple randomized controlled trials have shown that esketamine reduces depressive symptoms within hours and maintains these benefits over several weeks, with a favorable safety profile and minimal side effects observed in long-term use. The approval of esketamine for TRD has significant implications for healthcare practices and policies, offering a new therapeutic option that addresses the urgent needs of patients with severe depression.

Efficacy and safety of esketamine for perioperative depression in patients undergoing elective surgery: A meta-analysis of randomized controlled trials

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.

Clinical characteristics and treatment exposure of patients with marked treatment-resistant unipolar major depressive disorder: A RECOVER trial report

BACKGROUND

RECOVER is a randomized sham-controlled trial of vagus nerve stimulation and the largest such trial conducted with a psychiatric neuromodulation intervention.

OBJECTIVE

To describe pre-implantation baseline clinical characteristics and treatment history of patients with unipolar, major depressive disorder (MDD), overall and as a function of exposure to interventional psychiatric treatments (INTs), including electroconvulsive therapy, transcranial magnetic stimulation, and esketamine.

METHODS

Medical, psychiatric, and treatment records were reviewed by study investigators and an independent Study Eligibility Committee prior to study qualification. Clinical characteristics and treatment history (using Antidepressant Treatment History [Short] Form) were compared in those qualified (N = 493) versus not qualified (N = 228) for RECOVER, and among the qualified group as a function of exposure to INTs during the current major depressive episode (MDE).

RESULTS

Unipolar MDD patients who qualified for RECOVER had marked TRD (median of 11.0 lifetime failed antidepressant treatments), severe disability (median WHODAS score of 50.0), and high rate of baseline suicidality (77% suicidal ideation, 40% previous suicide attempts). Overall, 71% had received at least one INT. Compared to the no INT group, INT recipients were younger and more severely depressed (QIDS-C, QIDS-SR), had greater suicidal ideation, earlier diagnosis of MDD, and failed more antidepressant medication trials.

CONCLUSIONS

RECOVER-qualified unipolar patients had marked TRD and marked treatment resistance with most failing one or more prior INTs. Treatment with ≥1 INTs in the current MDE was associated with earlier age of MDD onset, more severe clinical presentation, and greater treatment resistance relative to patients without a history of INT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03887715.

Are "mystical experiences" essential for antidepressant actions of ketamine and the classic psychedelics?

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.

The role and mechanism of esketamine in preventing and treating remifentanil-induced hyperalgesia based on the NMDA receptor-CaMKII pathway

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.

[Atypical antipsychotics in the treatment of depression in affective disorders and schizophrenia (using the aripiprazole model)]

The review discusses aspects of the use of atypical antipsychotics in the treatment of depression in affective disorders and schizophrenia using the model of aripiprazole, a partial agonist of dopamine receptors. According to numerous studies, aripiprazole is the drug of choice for augmentative therapy of major depressive disorder, as well as for relieving and long-term maintenance monotherapy and combination therapy of various affective episodes of bipolar affective disorder and depression in schizophrenia.