1
|
Jiang Y, Dong Y, Hu H. The N-methyl-d-aspartate receptor hypothesis of ketamine's antidepressant action: evidence and controversies. Philos Trans R Soc Lond B Biol Sci 2024; 379:20230225. [PMID: 38853549 DOI: 10.1098/rstb.2023.0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/02/2024] [Indexed: 06/11/2024] Open
Abstract
Substantial clinical evidence has unravelled the superior antidepressant efficacy of ketamine: in comparison to traditional antidepressants targeting the monoamine systems, ketamine, as an N-methyl-d-aspartate receptor (NMDAR) antagonist, acts much faster and more potently. Surrounding the antidepressant mechanisms of ketamine, there is ample evidence supporting an NMDAR-antagonism-based hypothesis. However, alternative arguments also exist, mostly derived from the controversial clinical results of other NMDAR inhibitors. In this article, we first summarize the historical development of the NMDAR-centred hypothesis of rapid antidepressants. We then classify different NMDAR inhibitors based on their mechanisms of inhibition and evaluate preclinical as well as clinical evidence of their antidepressant effects. Finally, we critically analyse controversies and arguments surrounding ketamine's NMDAR-dependent and NMDAR-independent antidepressant action. A better understanding of ketamine's molecular targets and antidepressant mechanisms should shed light on the future development of better treatment for depression. This article is part of a discussion meeting issue 'Long-term potentiation: 50 years on'.
Collapse
Affiliation(s)
- Yihao Jiang
- Department of Affiliated Mental Health Center & Hangzhou Seventh People's Hospital and School of Brain Science and Brain Medicine, Zhejiang University School of Medicine , Hangzhou 310058, People's Republic of China
- Nanhu Brain-Computer Interface Institute, MOE Frontier Science Center for Brain Science and Brain-Machine Integration, State Key Laboratory of Brain-Machine Intelligence, New Cornerstone Science Laboratory, Zhejiang University , Hangzhou 311100, People's Republic of China
| | - Yiyan Dong
- Department of Affiliated Mental Health Center & Hangzhou Seventh People's Hospital and School of Brain Science and Brain Medicine, Zhejiang University School of Medicine , Hangzhou 310058, People's Republic of China
| | - Hailan Hu
- Department of Affiliated Mental Health Center & Hangzhou Seventh People's Hospital and School of Brain Science and Brain Medicine, Zhejiang University School of Medicine , Hangzhou 310058, People's Republic of China
- Nanhu Brain-Computer Interface Institute, MOE Frontier Science Center for Brain Science and Brain-Machine Integration, State Key Laboratory of Brain-Machine Intelligence, New Cornerstone Science Laboratory, Zhejiang University , Hangzhou 311100, People's Republic of China
| |
Collapse
|
2
|
Seshadri A, Prokop LJ, Singh B. Efficacy of intravenous ketamine and intranasal esketamine with dose escalation for Major depression: A systematic review and meta-analysis. J Affect Disord 2024; 356:379-384. [PMID: 38537759 DOI: 10.1016/j.jad.2024.03.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/09/2024] [Accepted: 03/24/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE Intravenous (IV) racemic ketamine and intranasal (IN) esketamine have demonstrated rapid antidepressant effects in treatment-resistant depression (TRD). This systematic review aims to evaluate the efficacy and safety of ketamine and esketamine at various dosages for depression. METHODS We included randomized controlled trials (RCTs) with parallel group dose comparison of ketamine and esketamine for depression/TRD. Ovid Medline, Embase, PsycINFO, Scopus and Cochrane databases were searched. Standardized mean differences were calculated using Hedges'-g to complete random effects meta-analysis. The efficacy outcomes were changes in depression outcomes for IV ketamine and IN esketamine respectively. Safety was assessed by reported adverse effects. RESULTS A random effects meta-analysis of studies (n = 12) showed efficacy in reducing depression symptoms with IV ketamine (Hedges'g = 1.52 [0.98-2.22], Z = 4.23, p < 0.001) and IN esketamine (Hedges' g = 0.31 [0.18-0.44], Z = 4.53, P < 0.001) compared to control/placebo. Treatment response was observed at IV ketamine doses ≤0.2 mg/kg, >0.2-0.5 mg/kg and > 0.5 mg/kg. Higher IV ketamine doses (>0.5 mg/kg) did not lead to greater treatment response. Esketamine doses of 56-84 mg were superior to 28 mg dose. LIMITATIONS Overall quality of evidence was low and limited by small number of studies. Publication bias was high. CONCLUSIONS This meta-analysis suggests that IV ketamine may be efficacious at doses as low as 0.2 mg/kg, with increasing dose response at 0.5 mg/kg, without demonstrable increased benefit at 1 mg/kg, based on a small number of studies. Efficacy for IN esketamine increases with doses above 28 mg with best response being found between 56 and 84 mg for reducing depressive symptoms.
Collapse
Affiliation(s)
- Ashok Seshadri
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA.
| | - Larry J Prokop
- Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Balwinder Singh
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
3
|
Calder CN, Kwan ATH, Teopiz KM, Wong S, Rosenblat JD, Mansur RB, Rhee TG, Ho R, Cao B, McIntyre RS. Number needed to treat (NNT) for ketamine and esketamine in adults with treatment-resistant depression: A systematic review and meta-analysis. J Affect Disord 2024; 356:753-762. [PMID: 38636712 DOI: 10.1016/j.jad.2024.04.039] [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: 01/18/2024] [Revised: 03/15/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Ketamine has been established as efficacious in adults living with Treatment-resistant Depression (TRD). Toward providing a quantifiable estimate of the clinical meaningfulness of the therapeutic benefit of ketamine, herein, we conduct a systematic review that aims to report the Number Needed to Treat (NNT) and the Number Needed to Harm (NNH). METHODS This systematic review searched Embase, Medline/Pubmed, PsycINFO and ClinicalTrials.gov from inception up to October 15th 2023, for placebo-controlled, Randomized Controlled Trials (RCTs) assessing racemic ketamine or esketamine therapy for unipolar TRD. We calculated NNT and NNH for ketamine treatments over various time points. RESULTS A total of 21 studies with 2042 participants were included. Racemic ketamine treatments had pooled NNTs for response of 7 at 4 h, 3 from one day to one week and 9 for studies at four weeks. Esketamine treatment was found to have a similar efficacy with an NNT of 2 at one day and 11 at four weeks. NNH values indicated low risk for ketamine treatments. LIMITATIONS Limitations in the data used include the possibility of functional unblinding and selective reporting bias. Moreover, the meta-analysis may have been limited in its precision by including low threshold definitions of treatment resistance (≥ 1 failed antidepressant) and low-dose ketamine treatments. CONCLUSION Herein, we determined that the NNT for ketamine treatment in adults living with TRD across different intervals of observation was <10. We conclude that the NNTs observed herein are highly clinically meaningful in this difficult to treat disorder.
Collapse
Affiliation(s)
| | - Angela T H Kwan
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada.
| | - Sabrina Wong
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
| | - Joshua D Rosenblat
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| | - Rodrigo B Mansur
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore.
| | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing 400715, PR China.
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
4
|
Liu R, Liu C, Feng D, Guo T, Wang Y. Pharmacovigilance of esketamine nasal spray: an analysis of the FDA adverse event reporting system database. Front Pharmacol 2024; 15:1414703. [PMID: 38948465 PMCID: PMC11211360 DOI: 10.3389/fphar.2024.1414703] [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: 04/09/2024] [Accepted: 05/20/2024] [Indexed: 07/02/2024] Open
Abstract
Esketamine nasal spray (ESK-NS) is a new drug for treatment-resistant depression, and we aimed to detect and characterize the adverse events (AEs) of ESK-NS using the Food and Drug Administration (FDA) adverse event reporting system (FAERS) database between 2019 Q1 and 2023 Q4. Reporting odds ratio (ROR), proportional reporting ratio (PRR), and multi-item gamma Poisson shrinker (MGPS) were performed to detect risk signals from the FAERS data to identify potential ESK-NS-AEs associations. A total of 14,606 reports on AEs with ESK-NS as the primary suspected drug were analyzed. A total of 518 preferred terms signals and 25 system organ classes mainly concentrated in psychiatric disorders (33.20%), nervous system disorders (16.67%), general disorders and administration site conditions (14.21%), and others were obtained. Notably, dissociation (n = 1,093, ROR 2,257.80, PRR 899.64, EBGM 876.86) exhibited highest occurrence rates and signal intensity. Moreover, uncommon but significantly strong AEs signals, such as hand-eye coordination impaired, feeling guilty, and feelings of worthlessness, were observed. Additionally, dissociative disorder (n = 57, ROR 510.92, PRR 506.70, EBGM 386.60) and sedation (n = 688, ROR 172.68, PRR 155.53, and EBGM 142.05) both presented strong AE signals, and the former is not recorded in the Summary of Product Characteristics (SmPC). In clinical applications, close attention should be paid to the psychiatric disorders and nervous system disorders, especially dissociation. Meanwhile, clinical professionals should be alert for the occurrence of AEs signals not mentioned in the SmPC and take preventive measures to ensure the safety of clinical use.
Collapse
Affiliation(s)
| | | | | | | | - Ying Wang
- Tianjin Anding Hospital, Tianjin, China
| |
Collapse
|
5
|
Wen W, Wenjing Z, Xia X, Duan X, Zhang L, Duomao L, Zeyou Q, Wang S, Gao M, Liu C, Li H, Ma J. Efficacy of ketamine versus esketamine in the treatment of perioperative depression: A review. Pharmacol Biochem Behav 2024; 242:173773. [PMID: 38806116 DOI: 10.1016/j.pbb.2024.173773] [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: 10/31/2023] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/30/2024]
Abstract
Depression is a significant factor contributing to postoperative occurrences, and patients diagnosed with depression have a higher risk for postoperative complications. Studies on cardiovascular surgery extensively addresses this concern. Several studies report that people who undergo coronary artery bypass graft surgery have a 20% chance of developing postoperative depression. A retrospective analysis of medical records spanning 21 years, involving 817 patients, revealed that approximately 40% of individuals undergoing coronary artery bypass grafting (CABG) were at risk of perioperative depression. Patients endure prolonged suffering from illness because each attempt with standard antidepressants requires several weeks to be effective. In addition, multi-drug combination adjuvants or combination medication therapy may alleviate symptoms for some individuals, but they also increase the risk of side effects. Conventional antidepressants primarily modulate the monoamine system, whereas different therapies target the serotonin, norepinephrine, and dopamine systems. Esketamine is a fast-acting antidepressant with high efficacy. Esketamine is the S-enantiomer of ketamine, a derivative of phencyclidine developed in 1956. Esketamine exerts its effect by targeting the glutaminergic system the glutaminergic system. In this paper, we discuss the current depression treatment strategies with a focus on the pharmacology and mechanism of action of esketamine. In addition, studies reporting use of esketamine to treat perioperative depressive symptoms are reviwed, and the potential future applications of the drug are presented.
Collapse
Affiliation(s)
- Wen Wen
- Beijing Anzhen Hospital, Capital Medical University
| | - Zhao Wenjing
- Beijing Anzhen Hospital, Capital Medical University
| | - Xing Xia
- Beijing Anzhen Hospital, Capital Medical University
| | | | - Liang Zhang
- Beijing Anzhen Hospital, Capital Medical University
| | - Lin Duomao
- Beijing Anzhen Hospital, Capital Medical University
| | - Qi Zeyou
- Beijing Anzhen Hospital, Capital Medical University
| | - Sheng Wang
- Beijing Anzhen Hospital, Capital Medical University
| | - Mingxin Gao
- Beijing Anzhen Hospital, Capital Medical University
| | | | - Haiyang Li
- Beijing Anzhen Hospital, Capital Medical University.
| | - Jun Ma
- Beijing Anzhen Hospital, Capital Medical University.
| |
Collapse
|
6
|
Di Vincenzo M, Martiadis V, Della Rocca B, Arsenio E, D’Arpa A, Volpicelli A, Luciano M, Sampogna G, Fiorillo A. Facts and myths about use of esketamine for treatment-resistant depression: a narrative clinical review. Front Psychiatry 2024; 15:1394787. [PMID: 38812489 PMCID: PMC11133709 DOI: 10.3389/fpsyt.2024.1394787] [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: 03/02/2024] [Accepted: 04/22/2024] [Indexed: 05/31/2024] Open
Abstract
Introduction and aims Treatment-resistant depression (TRD) occurs when at least two different antidepressants, taken at the right dosage, for adequate period of time and with continuity, fail to give positive clinical effects. Esketamine, the S-enantiomer of ketamine, was recently approved for TRD treatment from U.S. Food and Drug Administration and European Medicine Agency. Despite proved clinical efficacy, many misconceptions by clinicians and patients accompany this medication. We aimed to review the most common "false myths" regarding TRD and esketemine, counterarguing with evidence-based facts. Methods The keywords "esketamine", "treatment resistance depression", "depression", "myth", "mythology", "pharmacological treatment", and "misunderstanding" were entered in the main databases and combined through Boolean operators. Results Misconceptions regarding the TRD prevalence, clinical features and predictors have been found. With respect of esketamine, criteria to start treatment, dissociative symptoms, potential addiction and aspects of administration and monitoring, were found to be affected by false beliefs by clinicians and patients. Discussion and conclusion TRD represents a challenging condition, requiring precise diagnosis in order to achieve patient's full recovery. Esketamine has been proved as an effective medication to treat TRD, although it requires precautions. Evidence can inform clinical practice, in order to offer this innovative treatment to all patients with TRD.
Collapse
Affiliation(s)
- Matteo Di Vincenzo
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Vassilis Martiadis
- Department of Mental Health, Community Mental Health Center DS 25, Azienda Sanitaria Locale Napoli 1 Centro, Naples, Italy
| | - Bianca Della Rocca
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Eleonora Arsenio
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Andrea D’Arpa
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Antonio Volpicelli
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Mario Luciano
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Andrea Fiorillo
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| |
Collapse
|
7
|
Martin DM, Harvey AJ, Baune B, Berk M, Carter GL, Dong V, Glozier N, Glue P, Hood S, Hadzi-Pavlovic D, Hackett M, Mills N, Sarma S, Somogyi A, Rodgers A, Loo CK. Cognitive outcomes from the randomised, active-controlled Ketamine for Adult Depression Study (KADS). J Affect Disord 2024; 352:163-170. [PMID: 38378088 DOI: 10.1016/j.jad.2024.02.052] [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: 12/11/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Due to its rapid antidepressant effect, ketamine has recently been clinically translated for people with treatment-resistant depression. However, its cognitive profile remains unclear, particularly with repeated and higher doses. In the present study, we report the cognitive results from a recent large multicentre randomised controlled trial, the Ketamine for Adult Depression Study (KADS). METHODS In this randomised, double-blind, active-controlled, parallel group, multicentre phase 3 trial study we investigated potential cognitive changes following repeated treatment of subcutaneous racemic ketamine compared to an active comparator, midazolam, over 4 weeks, which involved two cohorts; Cohort 1 involved a fixed dose treatment protocol (0.5 mg/kg ketamine), Cohort 2 involved a dose escalation protocol (0.5-0.9 mg/kg) based on mood outcomes. Participants with treatment-resistant Major Depressive Disorder (MDD) were recruited from 7 mood disorder centres and were randomly assigned to receive ketamine (Cohort 1 n = 33; Cohort 2 n = 53) or midazolam (Cohort 1 n = 35; Cohort 2 n = 53) in a 1:1 ratio. Cognitive measurements were assessed at baseline and at the end of randomised treatment. RESULTS Results showed that in Cohort 1, there were no differences between ketamine and midazolam in cognitive outcomes. For Cohort 2, there was similarly no difference between conditions for cognitive outcomes. LIMITATIONS The study included two Cohorts with different dosing regimes. CONCLUSIONS The findings support the cognitive safety of repeated fixed and escalating doses at least in the short-term in people with treatment resistant MDD.
Collapse
Affiliation(s)
- Donel M Martin
- University of New South Wales, Sydney, NSW, Australia; Black Dog Institute, Sydney, NSW, Australia; The George Institute for Global Health, Sydney, NSW, Australia.
| | - Anna J Harvey
- University of New South Wales, Sydney, NSW, Australia; Black Dog Institute, Sydney, NSW, Australia
| | | | | | | | - Vanessa Dong
- University of New South Wales, Sydney, NSW, Australia; Black Dog Institute, Sydney, NSW, Australia
| | - Nick Glozier
- The University of Sydney, Sydney, NSW, Australia
| | - Paul Glue
- University of Otago, Dunedin, New Zealand
| | - Sean Hood
- University of Western Australia, Perth, WA, Australia
| | | | - Maree Hackett
- The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Shanthi Sarma
- Bond University, Southport, QLD, Australia; Mental Health and Special Services, Gold Coast Health, QLD, Australia
| | | | - Anthony Rodgers
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Colleen K Loo
- University of New South Wales, Sydney, NSW, Australia; Black Dog Institute, Sydney, NSW, Australia; The George Institute for Global Health, Sydney, NSW, Australia
| |
Collapse
|
8
|
Baldinger-Melich P, Spies M, Bozic I, Kasper S, Rujescu D, Frey R. Perspectives in treatment-resistant depression: esketamine and electroconvulsive therapy. Wien Klin Wochenschr 2024:10.1007/s00508-024-02358-w. [PMID: 38662240 DOI: 10.1007/s00508-024-02358-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/23/2024] [Indexed: 04/26/2024]
Abstract
Modern electroconvulsive therapy (ECT) and the approval of nasal esketamine for clinical use have significantly improved the approach to treatment-resistant depression (TRD), which is defined as non-response to at least two different courses of antidepressants with verified adherence to treatment, adequate dosage, and duration of treatment. The goal of this literature review is to present the newest evidence regarding efficacy and safety. Furthermore, we aim to provide an overview of future perspectives in this field of research, for example, regarding structural and molecular effects. Both treatment methods will be critically evaluated for their individual advantages, disadvantages, and response rates. Firstly, we will discuss the well-established method of ECT and its different treatment modalities. Secondly, we will discuss the properties of ketamine, the discovery of its antidepressive effects and the route to clinical approval of the esketamine nasal spray. We will comment on research settings which have evaluated intravenous ketamine against ECT. The decision-making process between esketamine nasal spray or ECT should include the assessment of contraindications, age, severity of disease, presence of psychotic symptoms, patient preference and treatment accessibility. We conclude that both treatment options are highly effective in TRD. If both are indicated, pragmatically esketamine will be chosen before ECT; however, ECT studies in ketamine non-responders are missing.
Collapse
Affiliation(s)
- Pia Baldinger-Melich
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Marie Spies
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Ina Bozic
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Siegfried Kasper
- Department of Molecular Neurosciences, Center for Brain Research, Vienna, Austria
| | - Dan Rujescu
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria
| | - Richard Frey
- Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry, Medical University Vienna, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences and Mental Health (C3NMH), Vienna, Austria.
| |
Collapse
|
9
|
Havlik JL, Wahid S, Teopiz KM, McIntyre RS, Krystal JH, Rhee TG. Recent Advances in the Treatment of Treatment-Resistant Depression: A Narrative Review of Literature Published from 2018 to 2023. Curr Psychiatry Rep 2024; 26:176-213. [PMID: 38386251 DOI: 10.1007/s11920-024-01494-4] [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] [Accepted: 02/05/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE OF REVIEW We review recent advances in the treatment of treatment-resistant depression (TRD), a disorder with very limited treatment options until recently. We examine advances in psychotherapeutic, psychopharmacologic, and interventional psychiatry approaches to treatment of TRD. We also highlight various definitions of TRD in recent scientific literature. RECENT FINDINGS Recent evidence suggests some forms of psychotherapy can be effective as adjunctive treatments for TRD, but not as monotherapies alone. Little recent evidence supports the use of adjunctive non-antidepressant pharmacotherapies such as buprenorphine and antipsychotics for the treatment of TRD; side effects and increased medication discontinuation rates may outweigh the benefits of these adjunctive pharmacotherapies. Finally, a wealth of recent evidence supports the use of interventional approaches such as electroconvulsive therapy, ketamine/esketamine, and transcranial magnetic stimulation for TRD. Recent advances in our understanding of how to treat TRD have largely expanded our knowledge of best practices in, and efficacy of, interventional psychiatric approaches. Recent research has used a variety of TRD definitions for study inclusion criteria; research on TRD should adhere to inclusion criteria based on internationally defined guidelines for more meaningfully generalizable results.
Collapse
Affiliation(s)
- John L Havlik
- Yale University School of Medicine, New Haven, CT, USA
| | - Syed Wahid
- The University of Chicago, Chicago, IL, USA
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, Canada
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Department of Pharmacology, University of Toronto, Toronto, Canada
| | - John H Krystal
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
- Department of Public Health Sciences, University of Connecticut, Farmington, CT, USA.
| |
Collapse
|
10
|
Wong S, Kwan ATH, Teopiz KM, Le GH, Meshkat S, Ho R, d'Andrea G, Cao B, Di Vincenzo JD, Rosenblat JD, McIntyre RS. A comparison between psilocybin and esketamine in treatment-resistant depression using number needed to treat (NNT): A systematic review. J Affect Disord 2024; 350:698-705. [PMID: 38244804 DOI: 10.1016/j.jad.2024.01.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Inadequate outcomes with monoamine-based treatments in depressive disorders are common and provide the impetus for mechanistically-novel treatments. Esketamine is a proven treatment recently approved for adults with Treatment-Resistant Depression (TRD) while psilocybin is an investigational treatment. Translation of the clinical meaningfulness for these foregoing agents in adults with TRD is required. Herein we evaluate the Number Needed to Treat (NNT) and Harm (NNH) of esketamine and psilocybin in adults with TRD. METHODS We conducted a systematic review of randomized controlled trials, comparing the clinical efficacy of oral psilocybin to the co-commencement of intranasal esketamine with an oral antidepressant in adults with TRD. RESULTS 25 mg psilocybin had a significant reduction in depressive symptoms at 21-days post-dose, the NNT was 5 [95 % CI = 3.1, 18.5]. Psilocybin-induced nausea had a significant NNH = 5. Fixed-dosed esketamine at 56 mg and 84 mg had a significant effect at 28-days post-dose, (NNT of 7 [95 % CI56mg = 3.5, 46.7], [95 % CI84mg = 3.6, 142.2]). Esketamine-induced headache, nausea, dizziness, and dissociation had NNHs <10. LIMITATIONS The preliminary results may only reflect a small portion of the patient population. These results require replication and longer term studies investigating maintenance therapy. CONCLUSION Relatively few pharmacologic agents are proven safe and effective in adults with TRD. NNT estimates for investigational psilocybin and esketamine in TRD indicate clinical meaningfulness. The NNH profile for both aforementioned agents is clinically acceptable. Our results underscore the clinical relevance of these treatment options in adults with TRD.
Collapse
Affiliation(s)
- Sabrina Wong
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Angela T H Kwan
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada
| | - Gia Han Le
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada; Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Shakila Meshkat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
| | - Giacomo d'Andrea
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing 400715, PR China
| | - Joshua D Di Vincenzo
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada; Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada; Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
11
|
Zhang J, Sun R, Cai Y, Peng B, Yang X, Gao K. Efficacy and Safety of Antidiabetic Agents for Major Depressive Disorder and Bipolar Depression: A Meta-Analysis of Randomized, Double-Blind, Placebo-Controlled Trials. J Clin Med 2024; 13:1172. [PMID: 38398483 PMCID: PMC10889473 DOI: 10.3390/jcm13041172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND This meta-analysis aimed to determine the efficacy and safety of antidiabetic agents in the treatment of major depressive disorder and bipolar depression. METHODS Randomized controlled trials (RCTs) of antidiabetic agents in major depressive disorder or bipolar depression were searched in three electronic databases and three clinical trial registry websites from their inception up to October 2023. The differences in changes in the depression rating scale scores from baseline to endpoint or pre-defined sessions, response rate, remission rate, rate of side effects and dropout rate between antidiabetic agents and placebo were meta-analyzed. RESULTS Six RCTs involving 399 participants were included in the final meta-analysis, which did not find that antidiabetics outperformed the placebo in reducing depressive symptoms. The standardized mean difference (SMD) in the depression scores from baseline to endpoint was 0.25 (95% CI -0.1, 0.61). However, a subgroup analysis found a significant difference between antidiabetics and placebos in reducing depressive symptoms in Middle Eastern populations, with an SMD of 0.89 (95% CI 0.44, 1.34). CONCLUSIONS The current meta-analysis does not support the efficacy of antidiabetics being superior to the placebo in the treatment of unipolar and bipolar depression. However, a subgroup analysis indicates that patients from the Middle East may benefit from adding an antidiabetic medication to their ongoing medication(s) for their depression. Larger studies with good-quality study designs are warranted.
Collapse
Affiliation(s)
- Jian Zhang
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
- Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, 10524 Euclid Ave, 12th Floor, Cleveland, OH 44106, USA
| | - Rongyi Sun
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Yang Cai
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Bo Peng
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
| | - Xi Yang
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
| | - Keming Gao
- Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, 10524 Euclid Ave, 12th Floor, Cleveland, OH 44106, USA
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| |
Collapse
|
12
|
Steffens DC. Treatment-Resistant Depression in Older Adults. N Engl J Med 2024; 390:630-639. [PMID: 38354142 PMCID: PMC10885705 DOI: 10.1056/nejmcp2305428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- David C Steffens
- From the Department of Psychiatry, University of Connecticut School of Medicine, Farmington
| |
Collapse
|
13
|
Kumari S, Chaudhry HA, Sagot A, Doumas S, Abdullah H, Alcera E, Solhkhah R, Afzal S. Exploring Esketamine's Therapeutic Outcomes as an FDA-Designated Breakthrough for Treatment-Resistant Depression and Major Depressive Disorder With Suicidal Intent: A Narrative Review. Cureus 2024; 16:e53987. [PMID: 38476783 PMCID: PMC10928016 DOI: 10.7759/cureus.53987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
The expansive spectrum of major depressive disorder (MDD) continues to pose challenges for psychiatrists to treat effectively. Oral antidepressant (OAD) medications that alter monoamine neurotransmitters, mainly selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs), have been the mainstay of therapy for decades. Although these drugs have been largely beneficial, a considerable subset of patients do not respond adequately to multiple conventional therapies administered for an appropriate length of time, leading to a diagnosis of treatment-resistant depression (TRD). Ketamine, a non-monoaminergic drug, has long been known for its beneficial effects on TRD when given intravenously (IV). Between 2019 and 2020, an intranasal formulation of the S (+) enantiomer of racemic ketamine, esketamine (ESK), was granted "breakthrough designation" by the FDA and approved for the indications of TRD and MDD patients exhibiting acute suicidal intent. The objective of this narrative review was to review the academic literature and collect clinical evidence that may corroborate intranasal ESK's effectiveness for its approved indications while addressing its safety and tolerability profile, adverse effects, and impact on cognition. An overview of the drug's origins, pharmacology, and standard treatment regimen are provided. The outcomes from double-blinded randomized control trials (DB-RCTs) of ESK are outlined to demonstrate the efficacy and safety data leading to its FDA approval, along with its long-term post-market safety outcomes. Comparative trials between ESK and ketamine are then evaluated to highlight ESK's consideration as a more practical alternative to ketamine in common clinical practice. The authors further discuss currently approved and developing therapies for TRD, propose future research directions, and identify the inherent limitations of the review and further research. To conduct the research required, three digital databases (PubMed, Medline, and ClinicalTrials.gov) were queried to search for key terms, including ketamine, esketamine, treatment-resistant depression, and biomarkers, using automation tools along with selective search engine results. After streamlining the results by title and abstract and removing duplicates, a total of 37 results were chosen, of which 18 are clinical trials. A reduction in the Montgomery-Asberg Depression Rating Scale (MADRS) score was the primary efficacy endpoint for most of these clinical trials. In conclusion, intranasal ESK, when used as an adjunct to market OADs, shows greater efficacy in treating TRD and MDD with suicidal intent compared to OADs and placebo alone and provides a more suitable alternative to IV ketamine. It is important to note that further research is required to fully understand the novel mechanism of action of ESK, as well as the establishment of a consensus definition of TRD, which may facilitate better detection and treatment protocols. More focused quantitative and qualitative ESK studies are needed, as well as those pertaining to its use in patients with co-existing mental illnesses.
Collapse
Affiliation(s)
- Suneeta Kumari
- Psychiatry, Hackensack Meridian Ocean Medical Center, Brick, USA
| | - Hassan A Chaudhry
- Medical School, Medical University of Lublin, Lublin, POL
- Psychiatry and Behavioral Sciences, Youth Neuroscience Organization, Tbilisi, GEO
| | - Adam Sagot
- Psychiatry, Hackensack Meridian Ocean Medical Center, Brick, USA
| | - Stacy Doumas
- Psychiatry, Hackensack Meridian Ocean Medical Center, Brick, USA
| | - Hussain Abdullah
- Psychiatry, Hackensack Meridian Ocean Medical Center, Brick, USA
| | - Eric Alcera
- Psychiatry, Hackensack Meridian Ocean Medical Center, Brick, USA
| | - Ramon Solhkhah
- Psychiatry, Northshore University Health System, Evanston, USA
| | - Saba Afzal
- Psychiatry, Hackensack Meridian Ocean Medical Center, Brick, USA
| |
Collapse
|
14
|
Hovda N, Gerrish W, Frizzell W, Shackelford R. A systematic review of the incidence of medical serious adverse events in sub-anesthetic ketamine treatment of psychiatric disorders. J Affect Disord 2024; 345:262-271. [PMID: 37875227 DOI: 10.1016/j.jad.2023.10.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/04/2023] [Accepted: 10/17/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Limited published data exists that collates serious adverse outcomes involving ketamine as a psychiatric intervention. This systematic review assesses the reported incidence of medical serious adverse events (MSAEs), including but not limited to cardiovascular events, in patients receiving sub-anesthetic doses of ketamine for psychiatric disorders to guide practitioners during treatment planning, risk-benefit analyses, and the informed consent process. METHODS Pubmed database was searched for clinical trials of sub-anesthetic ketamine for psychiatric disorders in non-pregnant adult patients. Of the 2275 articles identified, 93 met inclusion criteria, over half of which were published in 2017 or later. Only studies that reported adverse events were included, and the incidence of MSAEs was calculated. RESULTS Of the 3756 participants who received at least one sub-anesthetic dose of ketamine, four participants experienced a MSAE, resulting in an incidence of approximately 0.1 % of individuals. The four MSAEs resolved without reported sequelae. Eighty-three percent of studies reported screening for medical illness and exclusion of high-risk patients. There were no serious cardiac adverse events or deaths observed in any participants; however, most trials' study designs excluded those with high cardiovascular complication risk. LIMITATIONS Most studies were small, underpowered for detecting rare MSAEs, at potential high-risk of bias of non-report of MSAEs, and limited mostly to intranasal and intravenous routes. CONCLUSIONS Findings suggest that with basic medical screening there is a very low incidence of MSAEs including adverse cardiac or cerebrovascular events in individuals receiving sub-anesthetic ketamine for psychiatric disorders.
Collapse
Affiliation(s)
- Nicholas Hovda
- Sojourn Psychotherapy, Boise, United States of America; University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences, United States of America; Boise VAMC, Psychiatry & Behavioral Sciences Department, United States of America.
| | - Winslow Gerrish
- University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences, United States of America; Family Medicine Residency of Idaho - Boise, Full Circle Health, United States of America.
| | - William Frizzell
- University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences, United States of America; Boise VAMC, Psychiatry & Behavioral Sciences Department, United States of America.
| | - Ryan Shackelford
- Sojourn Psychotherapy, Boise, United States of America; University of Washington School of Medicine, Department of Psychiatry & Behavioral Sciences, United States of America; Family Medicine Residency of Idaho - Boise, Full Circle Health, United States of America.
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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.
Collapse
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.
| |
Collapse
|
17
|
Boudieu L, Mennetrier M, Llorca PM, Samalin L. The Efficacy and Safety of Intranasal Formulations of Ketamine and Esketamine for the Treatment of Major Depressive Disorder: A Systematic Review. Pharmaceutics 2023; 15:2773. [PMID: 38140113 PMCID: PMC10747365 DOI: 10.3390/pharmaceutics15122773] [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: 10/20/2023] [Revised: 12/02/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
Ketamine and its enantiomers represent an innovative glutamatergic agent as a treatment for individuals with treatment-resistant depression (TRD) and major depressive disorder (MDD) with suicidal ideation and behavior. Intranasal (IN) formulations could allow for quick onset of action on depressive symptoms as well as a reduction in side effects by bypassing the blood-brain barrier compared with administration via the intravenous route. The aim of this review was to provide an up-to-date analysis of the data on the efficacy and safety of IN ketamine and IN esketamine for the treatment of MDD. A systematic review following PRISMA guidelines was conducted. Databases (PubMed, Embase, MEDLINE, PsycINFO, and Google Scholar) were searched to capture articles about IN ketamine or IN esketamine for MDD. This systematic review highlighted the interest in IN routes of ketamine and esketamine for MDD patients with TRD or active suicidal ideation. They provide a rapid onset of antidepressant action within the first hours after administration. Nevertheless, the evidence of efficacy is stronger for IN esketamine than for IN ketamine in MDD patients. The safety profile appears to be acceptable for IN esketamine but requires further studies, and a more accurate IN delivery device is required for ketamine.
Collapse
Affiliation(s)
| | | | | | - Ludovic Samalin
- Department of Psychiatry, CHU Clermont-Ferrand, CNRS, Clermont Auvergne INP, Institut Pascal (UMR 6602), University of Clermont Auvergne, 63000 Clermont-Ferrand, France; (L.B.); (M.M.); (P.-M.L.)
| |
Collapse
|
18
|
Gebara MA, Brown PJ, Roose SP. Finally, New Hope for the Treatment of LLTRD. Am J Geriatr Psychiatry 2023; 31:1042-1044. [PMID: 37562991 DOI: 10.1016/j.jagp.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Marie Anne Gebara
- Department of Psychiatry (MAG), University of Pittsburgh, School of Medicine, Pittsburgh, PA.
| | - Patrick J Brown
- Department of Psychiatry (PJB, SPR), Columbia University College of Physicians and Surgeons, The New York State Psychiatric Institute, New York, NY
| | - Steven P Roose
- Department of Psychiatry (PJB, SPR), Columbia University College of Physicians and Surgeons, The New York State Psychiatric Institute, New York, NY
| |
Collapse
|
19
|
d'Andrea G, Chiappini S, McIntyre RS, Stefanelli G, Carullo R, Andriola I, Zanardi R, Martiadis V, Sensi SL, Sani G, Clerici M, Di Lorenzo G, Vita A, Pettorruso M, Martinotti G. Investigating the Effectiveness and Tolerability of Intranasal Esketamine Among Older Adults With Treatment-Resistant Depression (TRD): A Post-hoc Analysis from the REAL-ESK Study Group. Am J Geriatr Psychiatry 2023; 31:1032-1041. [PMID: 37479669 DOI: 10.1016/j.jagp.2023.06.016] [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: 05/10/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Treatment-resistant depression (TRD) is a serious and debilitating psychiatric disorder that frequently affects older patients. Esketamine nasal spray (ESK-NS) has recently been approved as a treatment for TRD, with multiple studies establishing its efficacy and tolerability. However, the real-world effectiveness, tolerability, and safety of this treatment in older adults is still unclear. OBJECTIVES To evaluate the efficacy and tolerability of ESK-NS in older subjects with TRD. METHODS This is a post-hoc analysis of the REAL-ESK study, a multicenter, retrospective, observational study. Participants here selected were 65 years or older at baseline. The Montgomery-Åsberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Rating Scale (HAM-A) were used to assess depressive and anxiety symptoms, respectively. Data were collected at three-time points: baseline, 1 month after the start of treatment (T1), and 3 months after treatment (T2). RESULTS The sample included older adults with TRD (n = 30). MADRS and HAM-A values decreased significantly at T1 (T0 versus T1: pholm <0.001, Cohen's d = 0.840) and T2 follow-ups (T0 versus T2: pholm <0.001, Cohen's d = 1.419). At T2, 53.3% of subjects were responders (MADRS score reduced ≥50%), while 33.33% were in remission (MADRS<10). ESK-NS-related adverse effects were in order of frequency dizziness (50%), followed by dissociation (33.3%), sedation (30%), and hypertension (13.33%). Six out of 30 participants (20%) discontinued treatment. CONCLUSIONS Our findings provide preliminary evidence of ESK-NS effectiveness in older adults with TRD, a highly debilitating depressive presentation. Furthermore, we observe high levels of treatment-emergent adverse events, which, in the majority of instances, did not require treatment suspension.
Collapse
Affiliation(s)
- Giacomo d'Andrea
- Department of Neurosciences, Imaging and Clinical Sciences (GDA, SC, GS, RCSLS, MP, GM), Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Stefania Chiappini
- Department of Neurosciences, Imaging and Clinical Sciences (GDA, SC, GS, RCSLS, MP, GM), Università degli Studi G. D'Annunzio, Chieti, Italy.
| | - Roger S McIntyre
- Department of Pharmacology and Toxicology (RSM), University of Toronto, Toronto, ON, Canada; Mood Disorders Psychopharmacology Unit (RSM), University Health Network, Toronto, ON, Canada; Department of Psychiatry (RSM), University of Toronto, Toronto, ON Canada; Braxia Health, Canadian Centre for Rapid Treatment Excellence (CRTCE) (RSM), Mississauga, ON, Canada; Brain and Cognition Discovery Foundation (RSM), Toronto, ON, Canada
| | - Giulia Stefanelli
- Department of Neurosciences, Imaging and Clinical Sciences (GDA, SC, GS, RCSLS, MP, GM), Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Rosalba Carullo
- Department of Neurosciences, Imaging and Clinical Sciences (GDA, SC, GS, RCSLS, MP, GM), Università degli Studi G. D'Annunzio, Chieti, Italy
| | | | - Raffaella Zanardi
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute (RZ), Mood Disorder Unit, Milan, Italy; Department of Clinical Neurosciences (RZ), University Vita-Salute San Raffaele, Milan, Italy
| | | | - Stefano L Sensi
- Department of Neurosciences, Imaging and Clinical Sciences (GDA, SC, GS, RCSLS, MP, GM), Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Gabriele Sani
- Department of Neurosciences, Section of Psychiatry (GS), Università Cattolica del Sacro Cuore, Rome; Department of Psychiatry, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS (GS), Rome
| | - Massimo Clerici
- Department of Mental Health and Addiction (MC), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery (MC), University of Milano-Bicocca, Monza, Italy
| | - Giorgio Di Lorenzo
- Chair of Psychiatry, Department of Systems Medicine (GDL), Tor Vergata University of Rome, Rome, Italy; IRCCS Fondazione Santa Lucia (GDL), Rome, Italy
| | - Antonio Vita
- Department of Clinical and Experimental Sciences (AV), University of Brescia, Brescia, Italy; Department of Mental Health and Addiction Services (AV), ASST Spedali Civili of Brescia, Brescia, Italy
| | - Mauro Pettorruso
- Department of Neurosciences, Imaging and Clinical Sciences (GDA, SC, GS, RCSLS, MP, GM), Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Giovanni Martinotti
- Department of Neurosciences, Imaging and Clinical Sciences (GDA, SC, GS, RCSLS, MP, GM), Università degli Studi G. D'Annunzio, Chieti, Italy
| |
Collapse
|
20
|
Hope J, Copolov D, Tiller J, Galbally M, Hopwood M, Newton R, Keks NA. What clinicians need to know about intranasal esketamine for treatment-resistant depression? Australas Psychiatry 2023; 31:841-845. [PMID: 37961848 PMCID: PMC10725109 DOI: 10.1177/10398562231211171] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
OBJECTIVE To review the usefulness of esketamine for treatment-resistant depression. METHOD Pivotal trials of intranasal esketamine in treatment-resistant depression were synthesized as a narrative review. RESULTS Esketamine is postulated to act through antagonism of N-methyl-D-aspartate (NMDA) glutamate receptors, but opioidergic effects may also be involved. Unlike intravenous ketamine, esketamine is given intranasally (under clinical observation), usually in addition to an oral antidepressant. Trials compared esketamine plus antidepressant versus placebo plus antidepressant. At 4 weeks, remission was 37% higher with esketamine/antidepressant than placebo/antidepressant. Speed of response and improvement in suicidality were comparable. In stable remitters on esketamine/antidepressant, 45% relapsed when esketamine was withdrawn over the following 6 months (whereas 25% relapsed on esketamine/antidepressant). Response appears less likely in patients with multiple antidepressant failures. Adverse effects include dissociation, dizziness, nausea, sedation, and headache but no psychosis. Hypertension affected 13%, especially older patients. Dose frequency is twice-weekly for 4 weeks, then weekly/fortnightly thereafter. No abuse has been reported. Unsubsidised cost may be beyond the reach of many Australians. CONCLUSION Intranasal esketamine plus antidepressant has been approved by regulators as moderately effective and acceptably tolerable for treatment-resistant depression. Cost is a drawback. Use often needs to be long-term and vigilance for abuse is essential.
Collapse
Affiliation(s)
- Judy Hope
- Mental Health Program, Eastern Health, Box Hill, VIC, Australia; Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia; Centre of Mental Health Education and Research, Delmont Private Hospital, Burwood, VIC, Australia
| | - David Copolov
- Department of Psychiatry, Monash University, Clayton, VIC, Australia
| | - John Tiller
- Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Megan Galbally
- Department of Psychiatry, Monash University, Clayton, VIC, Australia; Mental Health Program Monash Health, Clayton, VIC, Australia; Centre of Women's and Children's Mental Health, Melbourne, VIC, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, VIC, Australia
| | - Richard Newton
- Peninsula Health, Frankston, VIC, Australia; Monash University, Clayton, VIC, Australia
| | - Nicholas A Keks
- Monash Medical Centre, Clayton, VIC, Australia; Centre of Mental Health Education and Research, Delmont Private Hospital, Burwood, VIC, Australia
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Thornton NLR, Black W, Bognar A, Dagge D, Gitau T, Hua B, Joks G, King J, Lord A, Scott EM, Callander JS, Ting S, Liu D. Establishing an esketamine clinic in Australia: Practical recommendations and clinical guidance from an expert panel. Asia Pac Psychiatry 2023; 15:e12550. [PMID: 37932015 DOI: 10.1111/appy.12550] [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: 03/26/2023] [Revised: 09/27/2023] [Accepted: 10/20/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Major depressive disorder (MDD) can have severe impacts on function and quality of life. Up to one third of patients will have an inadequate response to their first line of treatment, with subsequent lines of therapy associated with lower remission rates and higher relapse rates. Recently esketamine has become available for Australian patients, and this agent provides an additional treatment option for those with MDD who have had an inadequate response to two or more antidepressant therapies during the current moderate to severe depressive episode. This paper provides an expert panel's practical recommendations and clinical guidance for establishing esketamine clinics in Australia. METHODS An expert panel (n = 11) comprising psychiatrists, mental health care nurses, pharmacists, and individuals with experience establishing esketamine clinics was convened in Sydney. The panel developed practical recommendations and clinical guidance, which were then further refined. RESULTS Five key areas were identified: practical considerations for esketamine clinic set-up, including multidisciplinary care considerations; patient selection; administering esketamine; adverse event management and long-term follow-up. CONCLUSIONS Guidance presented in this paper should assist Australian clinicians to set up an esketamine clinic, and provide practical advice on the infrastructure and clinical requirements for treatment of patients with this agent.
Collapse
Affiliation(s)
- Nicollette L R Thornton
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Warwick Black
- Older Persons Mental Health Service, Rural and Remote Mental Health Services, South Australia, Australia
| | | | - Daniel Dagge
- Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Teresia Gitau
- Monarch Mental Health Group, New South Wales, Australia
| | - Bruce Hua
- Perth Clinic, Western Australia, Australia
| | - Gero Joks
- Janssen-Cilag Pty Ltd, Sydney, New South Wales, Australia
| | - Jarrad King
- Janssen-Cilag Pty Ltd, Sydney, New South Wales, Australia
| | | | - Elizabeth M Scott
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Serena Ting
- Ramsay Clinic Albert Road, Victoria, Australia
| | - Dennis Liu
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| |
Collapse
|
23
|
Vecera CM, C. Courtes A, Jones G, Soares JC, Machado-Vieira R. Pharmacotherapies Targeting GABA-Glutamate Neurotransmission for Treatment-Resistant Depression. Pharmaceuticals (Basel) 2023; 16:1572. [PMID: 38004437 PMCID: PMC10675154 DOI: 10.3390/ph16111572] [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: 09/30/2023] [Revised: 10/22/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023] Open
Abstract
Treatment-resistant depression (TRD) is a term used to describe a particular type of major depressive disorder (MDD). There is no consensus about what defines TRD, with various studies describing between 1 and 4 failures of antidepressant therapies, with or without electroconvulsive therapy (ECT). That is why TRD is such a growing concern among clinicians and researchers, and it explains the necessity for investigating novel therapeutic targets beyond conventional monoamine pathways. An imbalance between two primary central nervous system (CNS) neurotransmitters, L-glutamate and γ-aminobutyric acid (GABA), has emerged as having a key role in the pathophysiology of TRD. In this review, we provide an evaluation and comprehensive review of investigational antidepressants targeting these two systems, accessing their levels of available evidence, mechanisms of action, and safety profiles. N-methyl-D-aspartate (NMDA) receptor antagonism has shown the most promise amongst the glutamatergic targets, with ketamine and esketamine (Spravato) robustly generating responses across trials. Two specific NMDA-glycine site modulators, D-cycloserine (DCS) and apimostinel, have also generated promising initial safety and efficacy profiles, warranting further investigation. Combination dextromethorphan-bupropion (AXS-05/Auvelity) displays a unique mechanism of action and demonstrated positive results in particular applicability in subpopulations with cognitive dysfunction. Currently, the most promising GABA modulators appear to be synthetic neurosteroid analogs with positive GABAA receptor modulation (such as brexanolone). Overall, advances in the last decade provide exciting perspectives for those who do not improve with conventional therapies. Of the compounds reviewed here, three are approved by the Food and Drug Administration (FDA): esketamine (Spravato) for TRD, Auvelity (dextromethorphan-bupropion) for major depressive disorder (MDD), and brexanolone (Zulresso) for post-partum depression (PPD). Notably, some concerns have arisen with esketamine and brexanolone, which will be detailed in this study.
Collapse
Affiliation(s)
- Courtney M. Vecera
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX 77054, USA
| | - Alan C. Courtes
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX 77054, USA
| | - Gregory Jones
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX 77054, USA
| | - Jair C. Soares
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, Houston, TX 77054, USA
| | - Rodrigo Machado-Vieira
- John S. Dunn Behavioral Sciences Center at UTHealth Houston, 5615 H.Mark Crosswell Jr St, Houston, TX 77021, USA
| |
Collapse
|
24
|
Oliveira-Maia AJ, Rive B, Morrens J, Godinov Y, Cabrieto J, Perualila N, Mulhern-Haughey S. Indirect adjusted comparison of 6-month clinical outcomes between esketamine nasal spray and other real-world polypharmacy treatment strategies for treatment resistant depression: results from the ICEBERG study. Front Psychiatry 2023; 14:1250987. [PMID: 38025416 PMCID: PMC10669145 DOI: 10.3389/fpsyt.2023.1250987] [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: 06/30/2023] [Accepted: 09/06/2023] [Indexed: 12/01/2023] Open
Abstract
Background The efficacy of esketamine nasal spray (NS) as a rapid-acting agent for treatment resistant depression (TRD) was demonstrated in comparisons with placebo, when both were given in addition to a newly initiated selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI). How esketamine NS compares with commonly used real-world (RW) polypharmacy treatment strategies is not known. Method ICEBERG was an adjusted indirect treatment comparison that analysed data from SUSTAIN-2 (NCT02497287; clinicaltrials.gov), a long-term, open-label study of esketamine NS plus SSRI/SNRI, and the European Observational TRD Cohort (EOTC; NCT03373253; clinicaltrials.gov), an observational study of routine clinical practice. Data were compared between patients receiving esketamine NS (SUSTAIN-2) and those from the EOTC treated with polypharmacy treatment strategies, either combination or augmentation. Analyses were adjusted for potential confounders, using rescaled average treatment effect among treated estimates. Threshold analyses were conducted to assess potential impact of unmeasured confounders on the robustness of analyses where esketamine NS was found to be significantly superior. Sensitivity analyses were used to understand the impact of analysis method selection and data handling. Results Esketamine NS treatment resulted in a higher probability of 6-month response (49.7% [95% confidence interval (CI) 45.6-53.9]) and remission (33.6% [95% CI 29.7-37.6]) versus RW polypharmacy (26.8% [95% CI 21.0-32.5] and 19.4%, [95% CI 14.2-24.6], respectively). Relative risk calculations showed esketamine NS was 1.859 (95% CI 1.474-2.345; p < 0.0001) times as likely to result in response and 1.735 (1.297-2.322; p = 0.0002) times as likely to result in remission versus RW polypharmacy at 6 months. Threshold and extensive sensitivity analyses supported that analyses of esketamine NS superiority were robust. Conclusion ICEBERG supports esketamine NS being superior to current RW individualized polypharmacy strategies, including augmentation, with benefits extending beyond acute use, to improved chance of 6-month response and remission. While unobserved confounding factors may certainly impact results of an indirect comparison, threshold analysis supported a low likelihood of this affecting the conclusions.To view an animated summary of this publication, please click on the Supplementary video.
Collapse
Affiliation(s)
- Albino J. Oliveira-Maia
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Lisbon, Portugal
| | | | | | | | | | | | | |
Collapse
|
25
|
Oliveira-Maia AJ, Morrens J, Rive B, Godinov Y, Cabrieto J, Perualila N, Barbreau S, Mulhern-Haughey S. ICEBERG study: an indirect adjusted comparison estimating the long-term benefit of esketamine nasal spray when compared with routine treatment of treatment resistant depression in general psychiatry. Front Psychiatry 2023; 14:1250980. [PMID: 38025433 PMCID: PMC10669153 DOI: 10.3389/fpsyt.2023.1250980] [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: 06/30/2023] [Accepted: 09/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background Treatment resistant depression (TRD) affects 10-30% of patients with major depressive disorder. In 4-week trials, esketamine nasal spray (NS) was efficacious vs. placebo when both were initiated in addition to a new selective serotonin or serotonin norepinephrine reuptake inhibitor. However, comparison with an extended range of real-world treatments (RWT) is lacking. Methods ICEBERG was an adjusted indirect treatment comparison using propensity score-based inverse probability weighting, performed on 6-month response and remission data from patients receiving esketamine NS plus oral antidepressant from the SUSTAIN-2 (NCT02497287; clinicaltrials.gov) study, compared with patients receiving other RWT from the European Observational TRD Cohort (EOTC; NCT03373253; clinicaltrials.gov) study. SUSTAIN-2 was a long-term open-label study of esketamine NS, while the EOTC was conducted at a time when esketamine NS was not available as RWT. Threshold and sensitivity analyses were conducted to assess how robust the primary analyses were. Results Patients receiving esketamine NS had a higher probability of 6-month response (49.7% [95% confidence interval (CI) 45.6-53.9]) and remission (33.6% [95% CI 29.7-37.6]) vs. patients receiving RWT (26.4% [95% CI 21.5-31.4] and 18.2% [95% CI 13.9-22.5], respectively), according to rescaled average treatment effect among treated estimates. Resulting adjusted odds ratios (OR) and relative risk (RR) favoured esketamine NS over RWT for 6-month response (OR 2.756 [95% CI 2.034-3.733], p < 0.0001; RR 1.882 [95% CI 1.534-2.310], p < 0.0001) and remission (OR 2.276 [95% CI 1.621-3.196], p < 0.0001; RR 1.847 [95% CI 1.418-2.406], p < 0.0001). Threshold analyses suggested that differences between the two studies were robust, and results were consistent across extensive sensitivity analyses. Conclusion ICEBERG supports that, at 6 months, esketamine NS has a substantial and significant benefit over RWT for patients with TRD. While results may be affected by unobserved confounding factors, threshold analyses suggested these were unlikely to impact the study conclusions.To view an animated summary of this publication, please click on the Supplementary video.
Collapse
Affiliation(s)
- Albino J. Oliveira-Maia
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Reif A, Bitter I, Buyze J, Cebulla K, Frey R, Fu DJ, Ito T, Kambarov Y, Llorca PM, Oliveira-Maia AJ, Messer T, Mulhern-Haughey S, Rive B, von Holt C, Young AH, Godinov Y. Esketamine Nasal Spray versus Quetiapine for Treatment-Resistant Depression. N Engl J Med 2023; 389:1298-1309. [PMID: 37792613 DOI: 10.1056/nejmoa2304145] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND In treatment-resistant depression, commonly defined as a lack of response to two or more consecutive treatments during the current depressive episode, the percentage of patients with remission is low and the percentage with relapse is high. The efficacy and safety of esketamine nasal spray as compared with extended-release quetiapine augmentation therapy, both in combination with ongoing treatment with a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI), in patients with treatment-resistant depression are unknown. METHODS In an open-label, single-blind (with raters unaware of group assignments), multicenter, phase 3b, randomized, active-controlled trial, we assigned patients, in a 1:1 ratio, to receive flexible doses (according to the summary of product characteristics) of esketamine nasal spray (esketamine group) or extended-release quetiapine (quetiapine group), both in combination with an SSRI or SNRI. The primary end point was remission, defined as a score of 10 or less on the Montgomery-Åsberg Depression Rating Scale (MADRS), at week 8 (scores range from 0 to 60, with higher scores indicating more severe depression). The key secondary end point was no relapse through week 32 after remission at week 8. All patients were included in the analysis; patients who discontinued the trial treatment were considered as having had an unfavorable outcome (i.e., they were grouped with patients who did not have remission or who had a relapse). Analyses of the primary and key secondary end points were adjusted for age and number of treatment failures. RESULTS Overall, 336 patients were assigned to the esketamine group and 340 to the quetiapine group. More patients in the esketamine group than in the quetiapine group had remission at week 8 (91 of 336 patients [27.1%] vs. 60 of 340 patients [17.6%]; P = 0.003) and had no relapse through week 32 after remission at week 8 (73 of 336 patients [21.7%] vs. 48 of 340 patients [14.1%]). Over 32 weeks of follow-up, the percentage of patients with remission, the percentage of patients with a treatment response, and the change in the MADRS score from baseline favored esketamine nasal spray. The adverse events were consistent with the established safety profiles of the trial treatments. CONCLUSIONS In patients with treatment-resistant depression, esketamine nasal spray plus an SSRI or SNRI was superior to extended-release quetiapine plus an SSRI or SNRI with respect to remission at week 8. (Funded by Janssen EMEA; ESCAPE-TRD ClinicalTrials.gov number, NCT04338321.).
Collapse
Affiliation(s)
- Andreas Reif
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Istvan Bitter
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Jozefien Buyze
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Kerstin Cebulla
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Richard Frey
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Dong-Jing Fu
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Tetsuro Ito
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Yerkebulan Kambarov
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Pierre-Michel Llorca
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Albino J Oliveira-Maia
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Thomas Messer
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Siobhán Mulhern-Haughey
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Benoît Rive
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Christian von Holt
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Allan H Young
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| | - Yordan Godinov
- From the Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital, Goethe University Frankfurt, and Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt (A.R.), Danuvius Klinik, Technische Universität München, Pfaffenhofen an der Ilm (T.M.), and Janssen Germany (K.C.) and Janssen EMEA (C.H.), Neuss - all in Germany; the Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary (I.B.); Janssen Pharmaceutica (J.B.) and Janssen EMEA (Y.K.) - both in Beerse, Belgium; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna (R.F.); Janssen Research and Development, New Jersey (D.-J.F.); Janssen EMEA, High Wycombe (T.I.), the Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, and South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham (A.H.Y.) - all in the United Kingdom; CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal, Clermont-Ferrand (P.-M.L.), and Janssen EMEA, Paris (B.R.) - both in France; Champalimaud Research and Clinical Center, Champalimaud Foundation, and NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa - both in Lisbon, Portugal (A.J.O.-M.); Janssen EMEA, Dublin (S.M.-H.); and Janssen EMEA, Sofia, Bulgaria (Y.G.)
| |
Collapse
|
27
|
Hashimoto K. Arketamine for cognitive impairment in psychiatric disorders. Eur Arch Psychiatry Clin Neurosci 2023; 273:1513-1525. [PMID: 36786865 PMCID: PMC9925943 DOI: 10.1007/s00406-023-01570-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/01/2023] [Indexed: 02/15/2023]
Abstract
Cognitive impairment has been observed in patients with various psychiatric disorders, including schizophrenia, major depressive disorder (MDD), and bipolar disorder (BD). Although modern therapeutic drugs can improve certain symptoms (i.e., psychosis, depression) in these patients, these drugs have not been found to improve cognitive impairment. The N-methyl-D-aspartate receptor antagonist (R,S)-ketamine has attracted attention as a rapidly acting antidepressant. In addition to its robust antidepressant effects, (R,S)-ketamine has been suggested to improve cognitive impairment in patients with MDD and BD, despite causing cognitive impairment in healthy control subjects. (R,S)-ketamine is a racemic mixture of equal amounts of (R)-ketamine (or arketamine) and (S)-ketamine (or esketamine). Arketamine has been found to have more potent antidepressant-like actions than esketamine in rodents. Interestingly, arketamine, but not esketamine, has been suggested to improve phencyclidine-induced cognitive deficits in mice. Furthermore, arketamine has been suggested to ameliorate cognitive deficits in rodent offspring after maternal immune activation. In the current article, it is proposed that arketamine has therapeutic potential for treating cognitive impairment in patients with psychiatric disorders. Additionally, the potential role of the gut-microbiome-brain axis in cognitive impairment in psychiatric disorders is discussed.
Collapse
Affiliation(s)
- Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| |
Collapse
|
28
|
Blaszczyk AT, Mathys M, Le J. A Review of Therapeutics for Treatment-Resistant Depression in the Older Adult. Drugs Aging 2023; 40:785-813. [PMID: 37596380 DOI: 10.1007/s40266-023-01051-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/20/2023]
Abstract
One-third of older adults with depression meet criteria for treatment resistance, typically defined as a lack of response to two or more adequate trials of an antidepressant. Treatment resistance contributes to an unfavorable prognosis, compromised medical outcomes, heightened disability, accelerated cognitive decline, and an elevated risk of developing dementia. Despite this significant morbidity, evidence is sparse for how to proceed with treatment in this population. Non-pharmacologic therapy (e.g., diet, psychotherapy) can be utilized as adjunctive therapy, despite little published evidence of benefit, given that the risks are low. Pharmacotherapy trials in the treatment-resistant late-life depression population lack strong methods and external validity; however, the use of venlafaxine as monotherapy and add-on therapy, as well as lithium, bupropion, or aripiprazole as add-on therapy to standard antidepressant therapy, have enough evidence that a trial with appropriate monitoring is a prudent strategy. Electroconvulsive therapy remains a well-studied safe therapy, especially when used as maintenance treatment once an initial cycle is completed but is traditionally underutilized in the treatment-resistant late-life depression population. Ensuring non-pharmacologic and pharmacologic strategies are optimized and given a sufficient trial in those with treatment-resistant late-life depression is the best we can do for this vulnerable population.
Collapse
Affiliation(s)
- Amie Taggart Blaszczyk
- Department of Pharmacy Practice, Texas Tech University HSC School of Pharmacy-Dallas/Fort Worth, 5920 Forest Park Rd, Dallas, TX, USA.
| | - Monica Mathys
- Department of Pharmacy Practice, Texas Tech University HSC School of Pharmacy-Dallas/Fort Worth, 5920 Forest Park Rd, Dallas, TX, USA
| | - Jennifer Le
- Harrison College of Pharmacy, Auburn University, Auburn, AL, USA
| |
Collapse
|
29
|
Borentain S, Desai P, Fu DJ, Nancy Chen L, Lane R, Mathews M, Canuso CM. Commentary on Cochrane review: "Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder". J Psychopharmacol 2023; 37:836-844. [PMID: 36218274 PMCID: PMC10399093 DOI: 10.1177/02698811221123046] [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: 11/16/2022]
Abstract
BACKGROUND Cochrane recently published a review of esketamine and other glutamate receptor modulators in depression. AIM To address the limitations of the review, analyses of esketamine data were conducted to provide additional perspective to the reviewers' interpretation of their findings. METHODS Response rate, remission rate, and change from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS) total score were determined using data from all esketamine phase 2/3 registration studies of treatment-resistant depression (TRD) and, separately, all esketamine phase 2/3 registration studies of major depressive disorder (MDD) and active suicidal ideation with intent. Outcomes were assessed at all timepoints (i.e., 24 h, 72 h (MDD with active suicidal intent only), and 1, 2, and 4 weeks). Enrollment criteria of the TRD studies were different than those of the studies of MDD and active suicidal ideation with intent, resulting in differences in patients' clinical characteristics and depression severity between the cohorts. Thus, we did not compare results between these cohorts (as was done in the Cochrane review). RESULTS/OUTCOMES In the combined TRD studies, a statistically significant between-group difference favored esketamine plus antidepressant over antidepressant plus placebo at 24 h (based on response, remission, and change in MADRS score), 1 week (change in MADRS score), 2 weeks (response and change in MADRS score), and 4 weeks (response, remission, and change in MADRS score). In the combined studies of MDD and active suicidal ideation with intent, the between-group difference was statistically different, favoring esketamine plus standard-of-care over placebo plus standard-of-care, at 24 h (response, remission, and change in MADRS score), 72 h and 1 week (change in MADRS score), 2 weeks (response), and 4 weeks (response, remission, and change in MADRS score). For both study types, the between-group difference in outcomes was not statistically significant at the other timepoints. CONCLUSIONS/INTERPRETATION Esketamine improves response, remission, and depressive symptoms as early as 24 h post-first dose among patients with TRD and among patients with MDD and active suicidal ideation with intent.
Collapse
Affiliation(s)
| | - Pooja Desai
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Dong-Jing Fu
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Li Nancy Chen
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Rosanne Lane
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Maju Mathews
- Janssen Research & Development, LLC, Titusville, NJ, USA
- Perception Neuroscience, New York, NY, USA (current employment)
| | - Carla M Canuso
- Janssen Research & Development, LLC, Titusville, NJ, USA
| |
Collapse
|
30
|
Nikolin S, Rodgers A, Schwaab A, Bahji A, Zarate C, Vazquez G, Loo C. Ketamine for the treatment of major depression: a systematic review and meta-analysis. EClinicalMedicine 2023; 62:102127. [PMID: 37593223 PMCID: PMC10430179 DOI: 10.1016/j.eclinm.2023.102127] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Background Intranasal esketamine has received regulatory approvals for the treatment of depression. Recently a large trial of repeated dose racemic ketamine also demonstrated efficacy in severe depression. However, uncertainties remain regarding comparative efficacy, dosage, and the time course of response. Methods In this systematic review and meta-analysis, we searched Embase, Medline, Pubmed, PsycINFO, and CENTRAL up to April 13, 2023, for randomised controlled trials (RCTs) investigating ketamine for depression. Two investigators independently assessed study eligibility and risk of bias and extracted the data on depression severity scores, response and remission rates, and all-cause dropouts. Multivariable mixed-effects meta-regressions incorporated drug formulation (racemic (Rac) or esketamine (Esket)) and dose (Low or High) as covariates. Treatment effects were assessed: immediately following the first dose, during further repeated dosing, and follow-up after the final dose of a treatment course. This study is registered with PROSPERO (CRD42021221157). Findings The systematic review identified 687 articles, of which 49 RCTs were eligible for analysis, comprising 3299 participants. Standardised mean differences (95% confidence intervals) immediately following the first/single treatment were moderate-high for all conditions (Rac-High: -0.73, -0.91 to -0.56; Esket-High: -0.48, -0.75 to -0.20; Rac-Low: -0.33, -0.54 to -0.12; Esket-Low: -0.55, -0.87 to -0.24). Ongoing effects during repeated dosing were significantly greater than the control for Rac-High (-0.61; -1.02 to -0.20) and Rac-Low (-0.55, -1.09 to -0.00), but not Esket-Low (-0.15, -0.49 to 0.19) or Esket-High (-0.22, -0.54 to 0.10). At follow-up effects remained significant for racemic ketamine (-0.65; -1.23 to -0.07) but not esketamine (-0.33; -0.96 to 0.31). All-cause dropout was similar between experiment and control conditions for both formulations combined (Odds Ratio = 1.18, 0.85-1.64). Overall heterogeneity varied from 5.7% to 87.6. Interpretation Our findings suggested that effect sizes for depression severity, as well as response and remission rates, were numerically greater for racemic ketamine than esketamine. Higher doses were more effective than low doses. Differences were evident in initial effects, ongoing treatment, and lasting effects after the final dose. Funding None.
Collapse
Affiliation(s)
- Stevan Nikolin
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Anees Bahji
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Carlos Zarate
- Section Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, National Institute of Mental Health, 10 Center Drive, MSC 1282, Building 10CRC, Room 7-5342, Bethesda, MD 20892, USA
| | - Gustavo Vazquez
- Section Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, National Institute of Mental Health, 10 Center Drive, MSC 1282, Building 10CRC, Room 7-5342, Bethesda, MD 20892, USA
| | - Colleen Loo
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| |
Collapse
|
31
|
Zheng W, Zhou YL, Wang CY, Lan XF, Ning YP. A comparative analysis of antidepressant and anti-suicidal effects of repeated ketamine infusions in elderly and younger adults with depression. J Affect Disord 2023; 334:145-151. [PMID: 37160235 DOI: 10.1016/j.jad.2023.04.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/02/2023] [Accepted: 04/29/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES This study aims to investigate the differences in safety and antidepressant effects of multi-infusion ketamine treatment between elderly and young adults with depression. METHODS The safety, antidepressant, and anti-suicidal effects of multi-infusion ketamine were compared between 19 elderly (≥50 years) and 116 younger (<50 years) adults with depression; all were treated with six ketamine infusions (0.5 mg/kg). Montgomery-Åsberg Depression Rating Scale (MADRS) was used to measure the depressive symptoms, and suicidal ideation was measured with Beck Scale for Suicide Ideation (SSI)-part 1, Hamilton Rating Scale for Depression (HAMD) item 3, and (MADRS) item 10. Dissociative and psychotomimetic symptoms were evaluated based on the Clinician-Administered Dissociative States Scale (CADSS) and the Brief Psychiatric Rating Scale (BPRS)-four items. RESULTS Multi-Ketamine infusions resulted in a lower (trend) antidepressant response (37.1 % versus 57.8 %) and antidepressant remission (15.8 % versus 47.4 %) in elderly patients with depression compared with younger patients with depression (all ps > 0.05). Interestingly, elderly patients with depression had a higher MADRS score after six ketamine infusions compared with younger patients (p = 0.04). No significant differences in SSI-part 1 scores, HAMD item 3 scores, MADRS item 10 scores, CADSS scores, and BPRS-four items scores were found between the two groups at any assessment point (all ps > 0.05). CONCLUSION Our study shows that repeated-dose infusions of ketamine may be a feasible treatment strategy in elderly Chinese patients with depression; however, elderly patients with depression may be less responsive to ketamine compared with younger adults with depression.
Collapse
Affiliation(s)
- Wei Zheng
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yan-Ling Zhou
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Cheng-Yu Wang
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiao-Feng Lan
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yu-Ping Ning
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China; The first School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China.
| |
Collapse
|
32
|
Zaki N, Chen LN, Lane R, Doherty T, Drevets WC, Morrison RL, Sanacora G, Wilkinson ST, Popova V, Fu DJ. Long-term safety and maintenance of response with esketamine nasal spray in participants with treatment-resistant depression: interim results of the SUSTAIN-3 study. Neuropsychopharmacology 2023; 48:1225-1233. [PMID: 37173512 PMCID: PMC10267177 DOI: 10.1038/s41386-023-01577-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/26/2023] [Accepted: 03/26/2023] [Indexed: 05/15/2023]
Abstract
Patients with treatment-resistant depression (TRD) have higher rates of relapse and pronounced decreases in daily functioning and health-related quality of life compared to patients with major depressive disorder who are not treatment-resistant, underscoring the need for treatment choices with sustained efficacy and long-term tolerability. Adults with TRD who participated in ≥1 of 6 phase 3 "parent" studies could continue esketamine treatment, combined with an oral antidepressant, by enrolling in phase 3, open-label, long-term extension study, SUSTAIN-3. Based on their status at parent-study end, eligible participants entered a 4-week induction phase followed by an optimization/maintenance phase, or directly entered the optimization/maintenance phase of SUSTAIN-3. Intranasal esketamine dosing was flexible, twice-weekly during induction and individualized to depression severity during optimization/maintenance. At the interim data cutoff (01 December 2020), 1148 participants were enrolled, 458 at induction and 690 at optimization/maintenance. Mean (median) cumulative duration of maintenance esketamine treatment was 31.5 (37.7) months (totaling 2769 cumulative patient-years). Common treatment-emergent adverse events (≥20%) were headache, dizziness, nausea, dissociation, somnolence, and nasopharyngitis. Mean Montgomery-Åsberg Depression Rating Scale (MADRS) total score decreased during induction, and this reduction persisted during optimization/maintenance (mean [SD] change from the baseline to the endpoint of each phase: induction -12.8 [9.73]; optimization/maintenance +1.1 [9.93]), with 35.6% and 46.1% of participants in remission (MADRS total score ≤12) at induction and optimization/maintenance endpoints, respectively. Improvement in depression ratings generally persisted among participants who remained in maintenance treatment, and no new safety signal was identified during long-term treatment (up to 4.5 years) using intermittent-dosed esketamine in conjunction with daily antidepressant.
Collapse
Affiliation(s)
- Naim Zaki
- Department of Neuroscience, Janssen Research & Development, LLC, Titusville, NJ, USA.
| | - Li Nancy Chen
- Department of Clinical Biostatistics, Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Rosanne Lane
- Department of Clinical Biostatistics, Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Teodora Doherty
- Department of Neuroscience, Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Wayne C Drevets
- Department of Neuroscience, Janssen Research & Development, LLC, San Diego, CA, USA
| | - Randall L Morrison
- Department of Neuroscience, Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Gerard Sanacora
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Samuel T Wilkinson
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Vanina Popova
- Department of Neuroscience, Janssen Research & Development Belgium, Beerse, Belgium
| | - Dong-Jing Fu
- Department of Neuroscience, Janssen Research & Development, LLC, Titusville, NJ, USA
| |
Collapse
|
33
|
Taillefer de Laportalière T, Jullien A, Yrondi A, Cestac P, Montastruc F. Reporting of harms in clinical trials of esketamine in depression: a systematic review. Psychol Med 2023; 53:4305-4315. [PMID: 37185130 DOI: 10.1017/s0033291723001058] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
While previous systematic reviews of trials evaluating conventional antidepressants highlighted inadequacies and inconsistencies in adverse event (AE) reporting, no evaluation is available on esketamine in resistant depression. The objective of this review was to assess quality of reporting AEs in all published clinical trials studying esketamine. It also aimed to compare the proportions of AEs reported in journal articles to those recorded in the ClinicalTrial.gov Registers. Clinical trials evaluating the efficacy and safety of esketamine in depression were searched using Medline and ClinicalTrials.gov. The quality of reporting harms was assessed using a 21-item checklist from the CONSORT Extension of Harms (1 point by item). The total quality score was graded into four categories: high (17-21), moderate (12-16), low (7-11) and very low (0-6). Ten clinical trials were included in the analysis. Nine trials were classified as 'low quality' with regard to safety, one trial was classified as 'moderate quality'. Compared to AEs recorded in ClinicalTrials.gov, we found that 41.5% of serious AEs and 39% of non-serious AEs were not reported in the published articles. Among them, the majority were psychiatric events but also cardiovascular events and 94% concerned patients from esketamine groups. Quality of AEs reporting in published clinical trials of esketamine was poor and harms were reported less frequently in journal publications than in ClinicalTrial.gov Registers. The study suggests that an assessment of the benefits/risks balance of esketamine based on the results reported in trial publications is flawed due to the poor accuracy and completeness of harm data.
Collapse
Affiliation(s)
- Tanguy Taillefer de Laportalière
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Toulouse University Hospital (CHU), Faculty of Medicine, Toulouse, France
| | - Adeline Jullien
- Department of Pharmacy, Toulouse University Hospital (CHU), Toulouse, France
| | - Antoine Yrondi
- Department of Medical Psychiatry, Toulouse University Hospital (CHU), Faculty of Medicine, Toulouse, France
- Treatment Resistant Depression Expert Center, FondaMental, Toulouse, France
- ToNIC Toulouse NeuroImaging Center, University Paul Sabatier Toulouse, INSERM, Toulouse, France
| | - Philippe Cestac
- Department of Pharmacy, Toulouse University Hospital (CHU), Toulouse, France
| | - François Montastruc
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Toulouse University Hospital (CHU), Faculty of Medicine, Toulouse, France
- Department of Medical Psychiatry, Toulouse University Hospital (CHU), Faculty of Medicine, Toulouse, France
- Centre d'Investigation Clinique 1436, Team PEPSS 'Pharmacologie En Population cohorteS et biobanqueS', Toulouse University Hospital, France
| |
Collapse
|
34
|
Floriano I, Silvinato A, Bernardo WM. The use of esketamine in the treatment of patients with oral antidepressant-resistant depression: systematic review and meta-analysis. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023D696. [PMID: 37377288 DOI: 10.1590/1806-9282.2023d696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/19/2023] [Indexed: 06/29/2023]
Abstract
The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field to standardize how to conduct, and to assist in the reasoning and decision-making of doctors. The information provided by this project must be critically evaluated by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical condition of each patient. Guideline conclusion: April 2023. Societies: Brazilian Medical Association.
Collapse
Affiliation(s)
- Idevaldo Floriano
- Cooperativa Baixa Mogiana, Evidence-Based Medicine - Mogi-Guaçu (SP), Brazil
| | - Antônio Silvinato
- Brazilian Medical Association, Evidence-Based Medicine - São Paulo (SP), Brazil
| | | |
Collapse
|
35
|
Abstract
Ketamine and esketamine have rapid-onset antidepressant effects and may be considered for the management of treatment-resistant depression. Intranasal esketamine has regulatory approval in the United States and European Union. Intravenous ketamine is often administered off-label as an antidepressant, though no standard operating procedures exist. Repeated administrations and the use of a concurrent standard antidepressant may maintain antidepressant effects of ketamine/esketamine. Possible adverse effects of ketamine and esketamine include psychiatric, cardiovascular, neurologic and genitourinary effects, and the potential for abuse. The long-term safety and efficacy of ketamine/esketamine as antidepressants require further study.
Collapse
Affiliation(s)
- Anna Feeney
- Department of Psychiatry, Clinical Trials Network and Institute, Massachusetts General Hospital, One Bowdoin Square, 9th Floor, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
| | - George I Papakostas
- Department of Psychiatry, Clinical Trials Network and Institute, Massachusetts General Hospital, One Bowdoin Square, 9th Floor, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
| |
Collapse
|
36
|
Subramanian S, Oughli HA, Gebara MA, Palanca BJA, Lenze EJ. Treatment-Resistant Late-Life Depression: A Review of Clinical Features, Neuropsychology, Neurobiology, and Treatment. Psychiatr Clin North Am 2023; 46:371-389. [PMID: 37149351 DOI: 10.1016/j.psc.2023.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Major depression is common in older adults (≥ 60 years of age), termed late-life depression (LLD). Up to 30% of these patients will have treatment-resistant late-life depression (TRLLD), defined as depression that persists despite two adequate antidepressant trials. TRLLD is challenging for clinicians, given several etiological factors (eg, neurocognitive conditions, medical comorbidities, anxiety, and sleep disruption). Proper assessment and management is critical, as individuals with TRLLD often present in medical settings and suffer from cognitive decline and other marks of accelerated aging. This article serves as an evidence-based guide for medical practitioners who encounter TRLLD in their practice.
Collapse
Affiliation(s)
- Subha Subramanian
- Department of Neurology, Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Psychiatry, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Hanadi A Oughli
- Department of Psychiatry, Semel Institute for Neuroscience, University of California Los Angeles, Los Angeles, CA, USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ben Julian A Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St Louis, MO, USA; Department of Psychiatry, Washington University School of Medicine in St. Louis, St Louis, MO, USA; Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis; Department of Biomedical Engineering, Washington University in St. Louis, St Louis, MO, USA; Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, USA; Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| |
Collapse
|
37
|
Szymkowicz SM, Gerlach AR, Homiack D, Taylor WD. Biological factors influencing depression in later life: role of aging processes and treatment implications. Transl Psychiatry 2023; 13:160. [PMID: 37160884 PMCID: PMC10169845 DOI: 10.1038/s41398-023-02464-9] [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: 11/24/2022] [Revised: 04/23/2023] [Accepted: 04/27/2023] [Indexed: 05/11/2023] Open
Abstract
Late-life depression occurring in older adults is common, recurrent, and malignant. It is characterized by affective symptoms, but also cognitive decline, medical comorbidity, and physical disability. This behavioral and cognitive presentation results from altered function of discrete functional brain networks and circuits. A wide range of factors across the lifespan contributes to fragility and vulnerability of those networks to dysfunction. In many cases, these factors occur earlier in life and contribute to adolescent or earlier adulthood depressive episodes, where the onset was related to adverse childhood events, maladaptive personality traits, reproductive events, or other factors. Other individuals exhibit a later-life onset characterized by medical comorbidity, pro-inflammatory processes, cerebrovascular disease, or developing neurodegenerative processes. These later-life processes may not only lead to vulnerability to the affective symptoms, but also contribute to the comorbid cognitive and physical symptoms. Importantly, repeated depressive episodes themselves may accelerate the aging process by shifting allostatic processes to dysfunctional states and increasing allostatic load through the hypothalamic-pituitary-adrenal axis and inflammatory processes. Over time, this may accelerate the path of biological aging, leading to greater brain atrophy, cognitive decline, and the development of physical decline and frailty. It is unclear whether successful treatment of depression and avoidance of recurrent episodes would shift biological aging processes back towards a more normative trajectory. However, current antidepressant treatments exhibit good efficacy for older adults, including pharmacotherapy, neuromodulation, and psychotherapy, with recent work in these areas providing new guidance on optimal treatment approaches. Moreover, there is a host of nonpharmacological treatment approaches being examined that take advantage of resiliency factors and decrease vulnerability to depression. Thus, while late-life depression is a recurrent yet highly heterogeneous disorder, better phenotypic characterization provides opportunities to better utilize a range of nonspecific and targeted interventions that can promote recovery, resilience, and maintenance of remission.
Collapse
Affiliation(s)
- Sarah M Szymkowicz
- Center for Cognitive Medicine, Department of Psychiatry and Behavioral Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew R Gerlach
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Damek Homiack
- Department of Psychiatry, University of Illinois-Chicago, Chicago, IL, USA
| | - Warren D Taylor
- Center for Cognitive Medicine, Department of Psychiatry and Behavioral Science, Vanderbilt University Medical Center, Nashville, TN, USA.
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Health System, Nashville, TN, USA.
| |
Collapse
|
38
|
Wu Z, Gan Y, Li N, Lan X, Wang C, Zhang F, Liu H, Li W, Ye Y, Hu Z, Ning Y, Zhou Y. Pain mediates the improvement of social functions of repeated intravenous ketamine in patients with unipolar and bipolar depression. J Affect Disord 2023; 334:152-158. [PMID: 37156269 DOI: 10.1016/j.jad.2023.04.122] [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: 03/17/2023] [Accepted: 04/29/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Previous research has shown that ketamine can improve social functions. In addition, evidence also suggests that ketamine can alleviate pain. Herein, we propose that ketamine-induced improvements in pain and depression are partially mediated by a reduction in pain. We aimed to determine whether improvements in pain-mediated changes in psychological function were associated with ketamine treatment. METHOD This trial included unipolar or bipolar patients (n = 103) who received 6 intravenous infusions (0.5 mg/kg) of ketamine over 2 weeks. The severity of current depressive symptoms and social function were evaluated by the Montgomery-Åsberg Depression Scale (MADRS), Self-Rating Depression Scale (SDS) and Global Assessment Function (GAF), respectively, at baseline and on day 13 and day 26. At the same time points, the three dimensions of pain, including the sensory index, affective index and present pain intensity (PPI), were measured by the Simple McGill Pain Scale (SF-MPQ). RESULTS The mixed model results showed that ketamine plays an important role in improving the psychosocial functioning of patients. There was a significant decrease from baseline to the day 13 and day 26, indicating that the pain index of the patient improved significantly. Mediation analysis showed that for SDS score (coef = -5.171, 95 % CI[-6.317, -4.025]) and GAF score (coef = 1.021, 95 % CI[0.848, 1.194]), the overall effect of ketamine was observable. The overall indirect and direct effects of ketamine on social functioning were significant (SDS: direct: coef = -1949 to -2114; total indirect: from 0.594 to 0.664; GAF: from 0.399 to 0.427; total indirect: coef = 0.593 to 0.664). The MADRS total score and emotional index were important mediators of the association between ketamine treatment and improvements in subjective and objective social functioning. CONCLUSION Depressive symptom severity and the affective index of pain partially mediated improvements in social function after six repeated ketamine treatments among patients with bipolar or unipolar depressive disorder.
Collapse
Affiliation(s)
- Zitao Wu
- School of Mental Health, Guangzhou Medical University, Guangzhou, China; The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Yujing Gan
- School of Mental Health, Guangzhou Medical University, Guangzhou, China; The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Nanxi Li
- School of Mental Health, Guangzhou Medical University, Guangzhou, China; The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Xiaofeng Lan
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Chengyu Wang
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Fan Zhang
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Haiyan Liu
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Weicheng Li
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Yanxiang Ye
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Zhibo Hu
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Yuping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Yanling Zhou
- The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China; Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China.
| |
Collapse
|
39
|
Wang SC, Yokoyama JS, Tzeng NS, Tsai CF, Liu MN. Treatment resistant depression in elderly. PROGRESS IN BRAIN RESEARCH 2023; 281:25-53. [PMID: 37806715 DOI: 10.1016/bs.pbr.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Treatment refractory depression (TRD) in the elderly is a common psychiatric disorder with high comorbidity and mortality. Older adults with TRD often have complicated comorbidities and several predisposing risk factors, which may lead to neuropsychiatric dysfunction and poor response to treatment. Several hypotheses suggest the underlying mechanisms, including vascular, immunological, senescence, or abnormal protein deposition. Treatment strategies for TRD include optimization of current medication dose, augmentation, switching to an alternative agent or class, and combination of different antidepressant classes, as well as nonpharmacological adjuvant interventions such as biophysical stimulation and psychotherapy. In summary, treatment recommendations for TRD in the elderly favor a multimodal approach, combining pharmacological and nonpharmacological treatments.
Collapse
Affiliation(s)
- Sheng-Chiang Wang
- School of Medicine, National Defense Medical Center, Taipei, Taiwan; Department of Psychiatry, Tri-Service General Hospital Songshan Branch, National Defense Medical Center, Taipei, Taiwan; Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, United States
| | - Jennifer S Yokoyama
- Memory and Aging Center, Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, United States; Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, United States
| | - Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan; Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Fen Tsai
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mu-N Liu
- Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| |
Collapse
|
40
|
Goh CL, Cheng JT, Palit M, Costello S, Barton DA. Pharmacological management of neuropsychiatric symptoms in geriatric traumatic brain injury: a scoping review. Brain Inj 2023; 37:356-371. [PMID: 36628484 DOI: 10.1080/02699052.2023.2166115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This scoping review aimed to summarize the existing knowledge base on the pharmacological management of neuropsychiatric symptoms in geriatric TBI and identify gaps in the literature to guide future research. METHODS Seven electronic databases and nine gray literature databases were systematically searched for articles that examined pharmacological management of neuropsychiatric symptoms in adults aged 65 years and over with TBI. The search was guided by four main concepts and selected based on inclusion criteria. Unpublished studies and abstract-only articles were excluded. RESULTS Eight studies met full inclusion criteria. Patterns of psychotropic medication prescription and prescribing principles for geriatric TBI were elucidated. There were no clear or consistent prescribing guidance. Therefore, prescribing recommendations could not be addressed. Current management is inferred from research primarily done in younger adults, or extrapolated from the literature and practice of treating other psychiatric and neurological disorders. CONCLUSION There are significant gaps in knowledge and no evidence-based guidelines for the treatment of neuropsychiatric symptoms in geriatric TBI. TBI among older adults is distinct from those of younger adults and thereby demands a unique approach to treatment and research. The authors' proposed guideline is an important first step in facilitating guideline development and future research.
Collapse
Affiliation(s)
- Cay Laurene Goh
- Department of Aged Psychiatry, Alfred Health, Melbourne, Australia
| | | | - Mithu Palit
- Acquired Brain Injury Rehabilitation Centre, Alfred Health, Melbourne, Australia
| | - Shane Costello
- School of Educational Psychology & Counselling, Monash University, Melbourne, Australia
| | | |
Collapse
|
41
|
Oughli HA, Gebara MA, Ciarleglio A, Lavretsky H, Brown PJ, Flint AJ, Farber NB, Karp JF, Mulsant BH, Reynolds CF, Roose SP, Yang L, Butters MA, Lenze EJ. Intravenous Ketamine for Late-Life Treatment-Resistant Depression: A Pilot Study of Tolerability, Safety, Clinical Benefits, and Effect on Cognition. Am J Geriatr Psychiatry 2023; 31:210-221. [PMID: 36529623 PMCID: PMC10839705 DOI: 10.1016/j.jagp.2022.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 11/18/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Evidence-based treatment options for late-life treatment-resistant depression (TRD) are limited. Ketamine is a promising treatment for TRD; however, there is a paucity of data on its safety and efficacy in older adults. METHODS In this pilot clinical trial, 25 adults aged ≥60 years with TRD received IV ketamine openly twice a week for 4 weeks; partial responders at the end of this acute phase were eligible to receive weekly infusions for 4 more weeks in a continuation phase. Acceptability, tolerability, and safety, including adverse and serious adverse events (AEs and SAEs), blood pressure changes, dissociation, craving, in addition to rates of depression response and remission were evaluated. The NIH Toolbox Cognitive Battery was used to assess specific measures of executive function (EF) and overall fluid cognition. RESULTS Completion rates were 88% for the acute phase and 100% for the continuation phase. No AEs resulted in participant discontinuation, and there were no SAEs. Treatment-emergent elevation of blood pressure, dissociation, and craving were transient and did not result in any participant discontinuation. Depressive symptoms improved significantly and 48% of participants responded. During the acute phase, the EF measures and the fluid cognition composite score improved (Cohen's d = 0.61), and these improvements were sustained in the continuation phase. CONCLUSION This pilot study suggests that repeated IV ketamine infusions are well-tolerated and are associated with improvement in depression and EF in older adults with TRD. These promising findings need to be confirmed and extended in a larger randomized controlled trial.
Collapse
Affiliation(s)
- Hanadi Ajam Oughli
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA
| | - Marie Anne Gebara
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Adam Ciarleglio
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, the George Washington University, Washington, DC
| | - Helen Lavretsky
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA
| | - Patrick J Brown
- Department of Psychiatry, Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute, New York, NY
| | - Alastair J Flint
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Centre for Mental Health, University Health Network, Toronto, Canada
| | - Nuri B Farber
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Jordan F Karp
- Department of Psychiatry, College of Medicine-Tucson, University of Arizona, Tucson, AZ
| | - Benoit H Mulsant
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Centre for Addiction and Mental Health, Toronto, Canada
| | - Charles F Reynolds
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Steven P Roose
- Department of Psychiatry, Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute, New York, NY
| | - Lei Yang
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Meryl A Butters
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
42
|
Scott F, Hampsey E, Gnanapragasam S, Carter B, Marwood L, Taylor RW, Emre C, Korotkova L, Martín-Dombrowski J, Cleare AJ, Young AH, Strawbridge R. Systematic review and meta-analysis of augmentation and combination treatments for early-stage treatment-resistant depression. J Psychopharmacol 2023; 37:268-278. [PMID: 35861202 PMCID: PMC10076341 DOI: 10.1177/02698811221104058] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) is a highly burdensome health condition, for which there are numerous accepted pharmacological and psychological interventions. Adjunctive treatment (augmentation/combination) is recommended for the ~50% of MDD patients who do not adequately respond to first-line treatment. We aimed to evaluate the current evidence for concomitant approaches for people with early-stage treatment-resistant depression (TRD; defined below). METHODS We systematically searched Medline and Institute for Scientific Information Web of Science to identify randomised controlled trials of adjunctive treatment of ⩾10 adults with MDD who had not responded to ⩾1 adequate antidepressant. The cochrane risk of bias (RoB) tool was used to assess study quality. Pre-post treatment meta-analyses were performed, allowing for comparison across heterogeneous study designs independent of comparator interventions. RESULTS In total, 115 trials investigating 48 treatments were synthesised. The mean intervention duration was 9 weeks (range 5 days to 18 months) with most studies assessed to have low (n = 57) or moderate (n = 51) RoB. The highest effect sizes (ESs) were from cognitive behavioural therapy (ES = 1.58, 95% confidence interval (CI): 1.09-2.07), (es)ketamine (ES = 1.48, 95% CI: 1.23-1.73) and risperidone (ES = 1.42, 95% CI: 1.29-1.61). Only aripiprazole and lithium were examined in ⩾10 studies. Pill placebo (ES = 0.89, 95% CI: 0.81-0.98) had a not inconsiderable ES, and only six treatments' 95% CIs did not overlap with pill placebo's (aripiprazole, (es)ketamine, mirtazapine, olanzapine, quetiapine and risperidone). We report marked heterogeneity between studies for almost all analyses. CONCLUSIONS Our findings support cautious optimism for several augmentation strategies; although considering the high prevalence of TRD, evidence remains inadequate for each treatment option.
Collapse
Affiliation(s)
- Fraser Scott
- South London and Maudsley NHS
Foundation Trust, London, UK
| | - Elliot Hampsey
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | | | - Ben Carter
- Department of Biostatistics and Health
Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College
London, London, UK
| | - Lindsey Marwood
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Rachael W Taylor
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Cansu Emre
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Lora Korotkova
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Jonatan Martín-Dombrowski
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Anthony J Cleare
- South London and Maudsley NHS
Foundation Trust, London, UK
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Allan H Young
- South London and Maudsley NHS
Foundation Trust, London, UK
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| | - Rebecca Strawbridge
- Department of Psychological Medicine,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London,
UK
| |
Collapse
|
43
|
Abstract
Treatment of major depressive disorder (MDD) including treatment-resistant depression (TRD) remains a major unmet need. Although there are several classes of dissimilar antidepressant drugs approved for MDD, the current drugs have either limited efficacy or are associated with undesirable side effects and withdrawal symptoms. The efficacy and side effects of antidepressant drugs are mainly attributed to their actions on different monoamine neurotransmitters (serotonin, norepinephrine, and dopamine). Development of new antidepressants with novel targets beyond the monoamine pathways may fill the unmet need in treatment of MDD and TRD. The recent approval of intranasal Esketamine (glutamatergic agent) in conjunction with an oral antidepressant for the treatment of adult TRD patients was the first step toward expanding beyond the monoamine targets. Several other glutamatergic (AXS-05, REL-1017, AV-101, SLS-002, AGN24175, and PCN-101) and GABAergic (brexanolone, zuranolone, and ganaxolone) drugs are currently in different stages of clinical development for MDD, TRD and other indications. The renaissance of psychedelic drugs and the emergence of preliminary positive clinical trial results with psilocybin, Ayahuasca, 5-methoxy-N,N-dimethyltryptamine (5-MeO-DMT), and lysergic acid diethylamide (LSD) may pave the way towards establishing this class of drugs as effective therapies for MDD, TRD and other neuropsychiatric disorders. Going beyond the monoamine targets appears to be an effective strategy to develop novel antidepressant drugs with superior efficacy, safety, and tolerability for the improved treatment of MDD and TRD.
Collapse
|
44
|
Rognoni C, Falivena C, Costa F, Armeni P. Cost-Utility Analysis of Esketamine for Patients with Treatment-Resistant Depression in Italy. PHARMACOECONOMICS 2023; 41:209-225. [PMID: 36662417 PMCID: PMC9883339 DOI: 10.1007/s40273-022-01220-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 06/17/2023]
Abstract
AIM Major depressive disorder is considered one of the most frequent diseases in the general population, and treatment-resistant depression (TRD) represents the subset with more significant clinical and social impact. Large, robust phase III studies have shown safety and efficacy of esketamine nasal spray plus SSRI/SNRI antidepressants (ADs) compared with SSRI/SNRI plus placebo nasal spray in patients with TRD. The main aim of this study was to perform a cost-utility analysis comparing esketamine plus ADs with ADs alone in TRD patients, from the societal perspective in Italy. A secondary analysis focused on the National Healthcare Service (NHS) perspective. METHODS A Markov multistate model has been developed to estimate quality-adjusted life years and economic outcomes of both treatment strategies over 5 years considering the initiation of esketamine in the different treatment lines, from 3 to 5 (3L-5L). The model has been populated with data from literature and real-world evidence. The analysis from the societal perspective considered direct healthcare costs and patients' productivity losses. In addition to the incremental cost-utility ratio (ICUR), the incremental net monetary benefit (INMB) has been calculated as (incremental benefit × WTP) - incremental cost and by applying a willingness-to-pay (WTP) of 50,000€/QALY. Deterministic and probabilistic sensitivity analyses have been performed to assess the robustness of the model results. RESULTS From the societal perspective, the ICUR ranged between 16,314€ and 22,133€ per QALY according to the different treatment lines, while it was over the threshold of 100,000€/QALY for the NHS perspective. The INMB was positive and ranged from 2259€ to 2744€ across treatment lines in the societal perspective; the INMB begins to occur earlier when moving towards subsequent lines of treatment (3.9 years for 3L, 3.6 years for 4L and 3.5 years for 5L). The analyses showed also that the advantage in terms of INMB is maintained for a wide range of societal preferences expressed by WTP thresholds, and in particular for values above 22,200€, 16,400€ and 17,100€ for 3L, 4L and 5L, respectively. CONCLUSION The study showed that esketamine may be a cost-effective opportunity from the societal perspective for the management of patients with treatment-resistant depression. In the future, data collected from observational studies or registries, which can include the collection of productivity losses and also costs sustained by the patients, will be able to provide further evidence in order to improve the reliability of the model results.
Collapse
Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Via Sarfatti 10, 20136, Milan, Italy.
| | - Camilla Falivena
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Via Sarfatti 10, 20136, Milan, Italy
| | - Francesco Costa
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Via Sarfatti 10, 20136, Milan, Italy
| | - Patrizio Armeni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Via Sarfatti 10, 20136, Milan, Italy
| |
Collapse
|
45
|
The therapeutic role of ketamine and esketamine in treating psychopathological domains of depression. Neuropharmacology 2023; 223:109299. [PMID: 36336068 DOI: 10.1016/j.neuropharm.2022.109299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
Over the past two decades, ketamine has emerged as a novel effective and rapid-acting antidepressant. While the vast majority of studies on ketamine have focused on its ability to reduce the severity of depression broadly, its effectiveness in specific domains such as cognition, anhedonia, suicidality, and workplace/social/scholastic functionality has been neglected. Similarly, current treatments (e.g., SSRIs and SNRIs) aim to improve overall depression severity, which often results in the persistence of one or more residual symptom domains and prevents full recovery to premorbid functionality. In this review, we narratively synthesize the literature pertaining to the effectiveness of ketamine in treating key domains of depressive symptomatology (i.e., cognition, anhedonia, suicidality, and psychosocial functionality). Our findings suggest that ketamine is effective across domains varyingly, with the strongest evidence being for its ability to reduce suicidality. The rapid acting nature of ketamine further supports its use in treating suicidality and potentially preventing the completion of suicide. Evidence for the effectiveness of ketamine in other domains is weak, primarily due to a lack of robust studies specifically designed to assess these domains as primary outcomes. Future studies should scrutinize the effects of ketamine on specific domains of depression to optimize its implementation.
Collapse
|
46
|
Vasiliu O. Esketamine for treatment‑resistant depression: A review of clinical evidence (Review). Exp Ther Med 2023; 25:111. [PMID: 36793329 PMCID: PMC9922941 DOI: 10.3892/etm.2023.11810] [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: 07/27/2022] [Accepted: 01/13/2023] [Indexed: 01/26/2023] Open
Abstract
Treatment-resistant depression (TRD) is a challenge for psychiatrists, even after more than seven decades since the first antidepressants were used in clinical practice. Non-monoaminergic-based drugs with antidepressant properties have been developed, but to date, only esketamine and brexanolone have been approved for TRD and postpartum depression, respectively. A narrative review on the efficacy and safety of esketamine in the main categories of depressive disorders has been conducted through four electronic databases (Pubmed, Cochrane, EMBASE and Clarivate/Web of Science) The primary objective of the present review was to find evidence that may support the usefulness of esketamine for patients diagnosed with TRD as well as data about its potential adverse effects in the short and long term. A total of 14 papers were reviewed, and their results support the recommendation of esketamine for treatment of TRD as an add-on to antidepressants, but more data is needed in order to assess its long-term efficacy and safety. It must also be mentioned that there have been a few trials which did not report a significant effect on the severity of depressive symptoms with esketamine in TRD, therefore, caution is indicated for patients initiated on this adjuvant agent. There has been insufficient data to formulate specific guidelines about esketamine administration because evidence about favorable or negative prognostic factors of this treatment has been lacking, and the duration of its administration has not been unanimously accepted. Novel directions for research have been identified, especially in the case of patients with TRD and substance use disorders, geriatric or bipolar depression or in major depression with psychotic features.
Collapse
Affiliation(s)
- Octavian Vasiliu
- Department of Psychiatry, ‘Dr. Carol Davila’ University Emergency Central Military Hospital, Bucharest 010816, Romania,Correspondence to: Dr Octavian Vasiliu, Department of Psychiatry, ‘Dr. Carol Davila’ University Emergency Central Military Hospital, 88 Mircea Vulcanescu Street, Bucharest 010816, Romania
| |
Collapse
|
47
|
Marwaha S, Palmer E, Suppes T, Cons E, Young AH, Upthegrove R. Novel and emerging treatments for major depression. Lancet 2023; 401:141-153. [PMID: 36535295 DOI: 10.1016/s0140-6736(22)02080-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 120.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 12/23/2022]
Abstract
Depression is common, costly, debilitating, and associated with increased risk of suicide. It is one of the leading global public health problems. Although existing available pharmacological treatments can be effective, their onset of action can take up to 6 weeks, side-effects are common, and recovery can require treatment with multiple different agents. Although psychosocial interventions might also be recommended, more effective treatments than those currently available are needed for people with moderate or severe depression. In the past 10 years, treatment trials have developed and tested many new targeted interventions. In this Review, we assess novel and emerging biological treatments for major depressive disorder, evaluate their putative brain and body mechanisms, and highlight how close each might be to clinical use.
Collapse
Affiliation(s)
- Steven Marwaha
- Institute for Mental Health, University of Birmingham, Birmingham, UK; Birmingham and Solihull Mental Health NHS Trust, Birmingham, UK
| | - Edward Palmer
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Trisha Suppes
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Emily Cons
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Allan H Young
- Centre for Affective Disorders, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK; Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Edgbaston, UK.
| |
Collapse
|
48
|
Zhao Y, Wu X, Tang M, Shi L, Gong S, Mei X, Zhao Z, He J, Huang L, Cui W. Late-life depression: Epidemiology, phenotype, pathogenesis and treatment before and during the COVID-19 pandemic. Front Psychiatry 2023; 14:1017203. [PMID: 37091719 PMCID: PMC10119596 DOI: 10.3389/fpsyt.2023.1017203] [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: 08/11/2022] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Late-life depression (LLD) is one of the most common mental disorders among the older adults. Population aging, social stress, and the COVID-19 pandemic have significantly affected the emotional health of older adults, resulting in a worldwide prevalence of LLD. The clinical phenotypes between LLD and adult depression differ in terms of symptoms, comorbid physical diseases, and coexisting cognitive impairments. Many pathological factors such as the imbalance of neurotransmitters, a decrease in neurotrophic factors, an increase in β-amyloid production, dysregulation of the hypothalamic-pituitary-adrenal axis, and changes in the gut microbiota, are allegedly associated with the onset of LLD. However, the exact pathogenic mechanism underlying LLD remains unclear. Traditional selective serotonin reuptake inhibitor therapy results in poor responsiveness and side effects during LLD treatment. Neuromodulation therapies and complementary and integrative therapies have been proven safe and effective for the treatment of LLD. Importantly, during the COVID-19 pandemic, modern digital health intervention technologies, including socially assistive robots and app-based interventions, have proven to be advantageous in providing personal services to patients with LLD.
Collapse
Affiliation(s)
- Yuanzhi Zhao
- Ningbo Kangning Hospital, Ningbo, Zhejiang, China
| | - Xiangping Wu
- Ningbo Kangning Hospital, Ningbo, Zhejiang, China
| | - Min Tang
- Department of Neurology, Ningbo Rehabilitation Hospital, Ningbo, Zhejiang, China
| | - Lingli Shi
- Ningbo Kangning Hospital, Ningbo, Zhejiang, China
| | - Shuang Gong
- Department of Neurology, Ningbo Rehabilitation Hospital, Ningbo, Zhejiang, China
| | - Xi Mei
- Ningbo Kangning Hospital, Ningbo, Zhejiang, China
| | - Zheng Zhao
- Ningbo Kangning Hospital, Ningbo, Zhejiang, China
| | - Jiayue He
- Ningbo Kangning Hospital, Ningbo, Zhejiang, China
| | - Ling Huang
- Ningbo Kangning Hospital, Ningbo, Zhejiang, China
| | - Wei Cui
- Ningbo Key Laboratory of Behavioral Neuroscience, Zhejiang Provincial Key Laboratory of Pathophysiology, Translational Medicine Center of Pain, Emotion and Cognition, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
- *Correspondence: Wei Cui,
| |
Collapse
|
49
|
Young AH, Abdelghani M, Juruena MF, Nikolova VL, Nilforooshan R. Early Clinical Experiences of Esketamine Nasal Spray in the UK in Adults with Treatment-Resistant Major Depressive Disorder: Advisory Panel Recommendations. Neuropsychiatr Dis Treat 2023; 19:433-441. [PMID: 36861011 PMCID: PMC9968662 DOI: 10.2147/ndt.s388392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/26/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE Treatment-resistant depression (TRD) is associated with profound morbidity for patients, placing a significant burden on those affected, the health service and wider society. Despite this, TRD remains chronically underserved in terms of viable treatment options. To address this gap, an advisory panel of psychiatrists and clinical researchers with experience in managing TRD convened to develop best practice statements on the use of esketamine nasal spray, one of the first TRD treatments to be licensed in 30 years. METHODS During a virtual meeting held on 12th November 2020, the advisory panel shared their experiences of using esketamine nasal spray in their clinical practice. The meeting focused on developing and refining recommendations for setting up and running an efficient esketamine nasal spray clinic for patients living with TRD. At the conclusion of the meeting, agreement was reached on all recommendation statements. RESULTS In setting up an esketamine nasal spray clinic, it is important to consider the logistical requirements involved and put measures in place to ensure it runs as efficiently as possible. Educating patients about the treatment and maintaining their well-being is paramount for preventing discontinuation. Putting in place checklists can be a useful strategy for ensuring treatment appointments run smoothly and safely. CONCLUSION Providing additional treatment options for the management of TRD, such as esketamine nasal spray, is likely to be key to improving the long-term outcomes of this underserved patient population.
Collapse
Affiliation(s)
- Allan H Young
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Mario F Juruena
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Maudsley Advanced Treatment Service (MATS), South London and Maudsley NHS Foundation Trust, London, UK
| | - Viktoriya L Nikolova
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ramin Nilforooshan
- Surrey and Borders Partnership NHS Foundation Trust, Leatherhead, UK.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| |
Collapse
|
50
|
Floriano I, Silvinato A, Bernardo WM. The use of esketamine in the treatment of patients with severe depression and suicidal ideation: systematic review and meta-analysis. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023D694. [PMID: 37194806 DOI: 10.1590/1806-9282.2023d694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/28/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Idevaldo Floriano
- Cooperativa Baixa Mogiana, Evidence-Based Medicine - Mogi-Guaçu (SP), Brazil
| | - Antônio Silvinato
- Cooperativa Baixa Mogiana, Evidence-Based Medicine - Mogi-Guaçu (SP), Brazil
- Brazilian Medical Association, Evidence-Based Medicine - São Paulo (SP), Brazil
| | - Wanderley Marques Bernardo
- Brazilian Medical Association, Evidence-Based Medicine - São Paulo (SP), Brazil
- Universidade de São Paulo, Faculty of Medicine - São Paulo (SP), Brazil
| |
Collapse
|