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Shafique H, Demers JC, Biesiada J, Golani LK, Cerne R, Smith JL, Szostak M, Witkin JM. ( R)-(-)-Ketamine: The Promise of a Novel Treatment for Psychiatric and Neurological Disorders. Int J Mol Sci 2024; 25:6804. [PMID: 38928508 PMCID: PMC11203826 DOI: 10.3390/ijms25126804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
NMDA receptor antagonists have potential for therapeutics in neurological and psychiatric diseases, including neurodegenerative diseases, epilepsy, traumatic brain injury, substance abuse disorder (SUD), and major depressive disorder (MDD). (S)-ketamine was the first of a novel class of antidepressants, rapid-acting antidepressants, to be approved for medical use. The stereoisomer, (R)-ketamine (arketamine), is currently under development for treatment-resistant depression (TRD). The compound has demonstrated efficacy in multiple animal models. Two clinical studies disclosed efficacy in TRD and bipolar depression. A study by the drug sponsor recently failed to reach a priori clinical endpoints but post hoc analysis revealed efficacy. The clinical value of (R)-ketamine is supported by experimental data in humans and rodents, showing that it is less sedating, does not produce marked psychotomimetic or dissociative effects, has less abuse potential than (S)-ketamine, and produces efficacy in animal models of a range of neurological and psychiatric disorders. The mechanisms of action of the antidepressant effects of (R)-ketamine are hypothesized to be due to NMDA receptor antagonism and/or non-NMDA receptor mechanisms. We suggest that further clinical experimentation with (R)-ketamine will create novel and improved medicines for some of the neurological and psychiatric disorders that are underserved by current medications.
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Affiliation(s)
- Hana Shafique
- Duke University School of Medicine, Durham, NC 27710, USA
| | - Julie C. Demers
- Indiana University-Purdue University, Indianapolis, IN 46202, USA; (J.C.D.); (J.B.)
| | - Julia Biesiada
- Indiana University-Purdue University, Indianapolis, IN 46202, USA; (J.C.D.); (J.B.)
| | - Lalit K. Golani
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, MA 02115, USA;
| | - Rok Cerne
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent Hospital, Indianapolis, IN 46260, USA; (R.C.); (J.L.S.)
| | - Jodi L. Smith
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent Hospital, Indianapolis, IN 46260, USA; (R.C.); (J.L.S.)
| | - Marta Szostak
- Department of Psychology, SWPS University, 03-815 Warsaw, Poland;
| | - Jeffrey M. Witkin
- Laboratory of Antiepileptic Drug Discovery, Ascension St. Vincent Hospital, Indianapolis, IN 46260, USA; (R.C.); (J.L.S.)
- Departments of Neuroscience and Trauma Research, Ascension St. Vincent Hospital, Indianapolis, IN 46260, USA
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Zhang S, Pu Y, Liu J, Li L, An C, Wu Y, Zhang W, Zhang W, Qu S, Yan W. Exploring the multifaceted potential of (R)-ketamine beyond antidepressant applications. Front Pharmacol 2024; 15:1337749. [PMID: 38666026 PMCID: PMC11043571 DOI: 10.3389/fphar.2024.1337749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
(R, S)- and (S)-ketamine have made significant progress in the treatment of treatment-resistant depression (TRD) and have become a research focus in recent years. However, they both have risks of psychomimetic effects, dissociative effects, and abuse liability, which limit their clinical use. Recent preclinical and clinical studies have shown that (R)-ketamine has a more efficient and lasting antidepressant effect with fewer side effects compared to (R, S)- and (S)-ketamine. However, a recent small-sample randomized controlled trial found that although (R)-ketamine has a lower incidence of adverse reactions in adult TRD treatment, its antidepressant efficacy is not superior to the placebo group, indicating its antidepressant advantage still needs further verification and clarification. Moreover, an increasing body of research suggests that (R)-ketamine might also have significant applications in the prevention and treatment of medical fields or diseases such as cognitive disorders, perioperative anesthesia, ischemic stroke, Parkinson's disease, multiple sclerosis, osteoporosis, substance use disorders, inflammatory diseases, COVID-19, and organophosphate poisoning. This article briefly reviews the mechanism of action and research on antidepressants related to (R)-ketamine, fully revealing its application potential and development prospects, and providing some references and assistance for subsequent expanded research.
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Affiliation(s)
- Senbing Zhang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Anesthesiology, Xianning Central Hospital, The First Affiliated Hospital of Hubei University of Science and Technology, Xianning, Hubei, China
| | - Yanzhu Pu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Jianning Liu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Lewen Li
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Chibing An
- Department of Anesthesiology, Xianning Central Hospital, The First Affiliated Hospital of Hubei University of Science and Technology, Xianning, Hubei, China
| | - Yumin Wu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenjie Zhang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenxia Zhang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Song Qu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenjun Yan
- Department of Anesthesiology, Gansu Provincial Hospital, Lanzhou, Gansu, China
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Zhou L, Duan J. The role of NMDARs in the anesthetic and antidepressant effects of ketamine. CNS Neurosci Ther 2024; 30:e14464. [PMID: 37680076 PMCID: PMC11017467 DOI: 10.1111/cns.14464] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/19/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND As a phencyclidine (PCP) analog, ketamine can generate rapid-onset and substantial anesthetic effects. Contrary to traditional anesthetics, ketamine is a dissociative anesthetic and can induce loss of consciousness in patients. Recently, the subanaesthetic dose of ketamine was found to produce rapid-onset and lasting antidepressant effects. AIM However, how different concentrations of ketamine can induce diverse actions remains unclear. Furthermore, the molecular mechanisms underlying the NMDAR-mediated anesthetic and antidepressant effects of ketamine are not fully understood. METHOD In this review, we have introduced ketamine and its metabolism, summarized recent advances in the molecular mechanisms underlying NMDAR inhibition in the anesthetic and antidepressant effects of ketamine, explored the possible functions of NMDAR subunits in the effects of ketamine, and discussed the future directions of ketamine-based anesthetic and antidepressant drugs. RESULT Both the anesthetic and antidepressant effects of ketamine were thought to be mediated by N-methyl-D-aspartate receptor (NMDAR) inhibition. CONCLUSION The roles of NMDARs have been extensively studied in the anaesthetic effects of ketamine. However, the roles of NMDARs in antidepressant effects of ketamine are complicated and controversial.
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Affiliation(s)
- Liang Zhou
- Department of Pharmacology, College of Pharmaceutical SciencesSoochow UniversitySuzhouChina
| | - Jingjing Duan
- Department of Anatomy and Neurobiology, Zhongshan School of MedicineSunYat‐sen UniversityGuangzhouChina
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Hashimoto K. Are "mystical experiences" essential for antidepressant actions of ketamine and the classic psychedelics? Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01770-7. [PMID: 38411629 DOI: 10.1007/s00406-024-01770-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/22/2024] [Indexed: 02/28/2024]
Abstract
The growing interest in the rapid and sustained antidepressant effects of the dissociative anesthetic ketamine and classic psychedelics, such as psilocybin, is remarkable. However, both ketamine and psychedelics are known to induce acute mystical experiences; ketamine can cause dissociative symptoms such as out-of-body experience, while psychedelics typically bring about hallucinogenic experiences, like a profound sense of unity with the universe or nature. The role of these mystical experiences in enhancing the antidepressant outcomes for patients with depression is currently an area of ongoing investigation and debate. Clinical studies have shown that the dissociative symptoms following the administration of ketamine or (S)-ketamine (esketamine) are not directly linked to their antidepressant properties. In contrast, the antidepressant potential of (R)-ketamine (arketamine), thought to lack dissociative side effects, has yet to be conclusively proven in large-scale clinical trials. Moreover, although the activation of the serotonin 5-HT2A receptor is crucial for the hallucinogenic effects of psychedelics in humans, its precise role in their antidepressant action is still under discussion. This article explores the importance of mystical experiences in enhancing the antidepressant efficacy of both ketamine and classic psychedelics.
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Affiliation(s)
- Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, 1-8-1 Inohana, Chiba, 260-8670, Japan.
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Tiliwaerde M, Gao N, Yang Y, Jin Z. A novel NMDA receptor modulator: the antidepressant effect and mechanism of GW043. CNS Neurosci Ther 2024; 30:e14598. [PMID: 38332552 PMCID: PMC10853642 DOI: 10.1111/cns.14598] [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] [Revised: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 02/10/2024] Open
Abstract
AIMS The N-methyl-D-aspartate (NMDA) receptor (NMDAR) has been proven to be strongly correlated with rapid antidepressant effects. Here, GW043, as a new compound targeting NMDAR, we explored its antidepressant effects and its mechanism of action. METHODS Our study utilized electrophysiological techniques to confirm the effect of GW043 on NMDAR currents. Additionally, we assessed the selectivity of GW043 through high-throughput receptor-ligand binding experiments. The antidepressant properties of GW043 were examined using rodent behavioral models including the Forced Swim Test (FST), Tail Suspension Test (TST), and Chronic Unpredictable Mild Stress (CUMS). Mechanistic insight into GW043's onset was gained through western blot analysis, BrdU staining, Golgi staining, and electrophysiological techniques. RESULTS Electrophysiological studies indicated that GW043 acts as a partial agonist of NMDAR. Behavioral experiments confirmed the antidepressant effect of GW043 in rodents. Mechanistic investigations revealed that GW043 modulates synaptic plasticity through the LTP and BDNF-mTOR pathways, consequently leading to an increase in the number of newborn neurons and subsequent antidepressant effects. CONCLUSION Our findings disclose that GW043, as a partial agonist of NMDAR, can reverse depression-like behaviors in rats by modulating synaptic plasticity, indicating its potential as an antidepressant agent.
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Affiliation(s)
- Murezati Tiliwaerde
- Department of Pharmacology, School of Basic Medical SciencesCapital Medical UniversityBeijingChina
| | - Nana Gao
- Department of Gastrointestinal Surgery and Clinical Nutrition, Beijing Shijitan HospitalCaptial Medical UniversityBeijingChina
| | - Yaqi Yang
- Department of Pharmacology, School of Basic Medical SciencesCapital Medical UniversityBeijingChina
- Department of Pharmacy, Beijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Zengliang Jin
- Department of Pharmacology, School of Basic Medical SciencesCapital Medical UniversityBeijingChina
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Wilkowska A, Cubała WJ. Short-term ketamine use in bipolar depression: a review of the evidence for short-term treatment management. Front Psychiatry 2023; 14:1322752. [PMID: 38144471 PMCID: PMC10739517 DOI: 10.3389/fpsyt.2023.1322752] [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: 10/16/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023] Open
Abstract
Bipolar depression constitutes a major problem in psychiatry. It correlates with high suicidality, treatment resistance, chronicity, and poor quality of life. Registered treatment for bipolar depression is limited and insufficient. There is an urgent need for implementing new therapeutic strategies. Intranasal ketamine's enantiomer-esketamine is a novel rapid-acting antidepressant with proven efficacy in treatment-resistant depression. Research on bipolar depression, although not as comprehensive, indicates that it may be a viable and safe substitute with minimal risk for mood polarity changes. Reports suggest that ketamine treatment in bipolar depression may reduce suicidal tendencies, decrease anhedonia, and alleviate anxiety. Ketamine's mood-stabilizing properties are also hypothesized. In this narrative review, we focus on ketamine use as an add-on to standard medication for the acute treatment of bipolar depression.
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Affiliation(s)
- Alina Wilkowska
- Department of Psychiatry, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Wu G, Xu H. A synopsis of multitarget therapeutic effects of anesthetics on depression. Eur J Pharmacol 2023; 957:176032. [PMID: 37660970 DOI: 10.1016/j.ejphar.2023.176032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/05/2023]
Abstract
Depression is a profound mental disorder that dampens the mood and undermines volition, which exhibited an increased incidence over the years. Although drug-based interventions remain the primary approach for depression treatment, the available medications still can't satisfy the patients. In recent years, the newly discovered therapeutic targets such as N-methyl-D-aspartate (NMDA) receptor, α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA) receptor, and tyrosine kinase B (TrkB) have brought new breakthroughs in the development of antidepressant drugs. Moreover, it has come to light that certain anesthetics possess pharmacological mechanisms intricately linked to the aforementioned therapeutic targets for depression. At present, numerous preclinical and clinical studies have explored the therapeutic effects of anesthetic drugs such as ketamine, isoflurane, N2O, and propofol, on depression. These investigations suggested that these drugs can swiftly ameliorate patients' depression symptoms and engender long-term effects. In this paper, we provide a comprehensive review of the research progress and potential molecular mechanisms of various anesthetic drugs for depression treatment. By shedding light on this subject, we aim to facilitate the development and clinical implementation of new antidepressant drugs based on anesthetic medications.
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Affiliation(s)
- Guowei Wu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, P.R. China
| | - Hongwei Xu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, P.R. China.
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Fancy F, Haikazian S, Johnson DE, Chen-Li DCJ, Levinta A, Husain MI, Mansur RB, Rosenblat JD. Ketamine for bipolar depression: an updated systematic review. Ther Adv Psychopharmacol 2023; 13:20451253231202723. [PMID: 37771417 PMCID: PMC10524067 DOI: 10.1177/20451253231202723] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/31/2023] [Indexed: 09/30/2023] Open
Abstract
Background The therapeutic potential of subanesthetic doses of ketamine appears promising in unipolar depression; however, its effectiveness in treating bipolar depression (BD) remains uncertain. Objective This systematic review aimed to summarize findings on the use of ketamine for the treatment of BD by assessing its efficacy, safety, and tolerability. Design Systematic review. Methods We conducted a systematic review of studies that investigated the use of ketamine for adults with BD. We searched PubMed and Embase for relevant randomized-controlled trials, open-label trials, and retrospective chart analyses published from inception to 13 March 2023. Results Eight studies were identified [pooled n = 235; mean (SD) age: 45.55 (5.54)]. All participants who received intravenous (IV) ketamine were administered a dose of 0.5-0.75 mg/kg as an adjunctive treatment to a mood-stabilizing agent, whereas participants who received esketamine were administered a dosage ranging from 28 to 84 mg. Flexible dosing was used in real-world analyses. A total of 48% of participants receiving ketamine achieved a response (defined as ⩾50% reduction in baseline depression severity), whereas only 5% achieved a response with a placebo. Real-world studies demonstrated lower rates of response (30%) compared to the average across clinical trials (63%). Reductions in suicidal ideation were noted in some studies, although not all findings were statistically significant. Ketamine and esketamine were well tolerated in most participants; however, six participants (2% of the overall sample pool, 5 receiving ketamine) developed hypomanic/manic symptoms after infusions. Significant dissociative symptoms were observed at the 40-min mark in some trials. Conclusion Preliminary evidence suggests IV ketamine as being safe and effective for the treatment of BD. Future studies should focus on investigating the effects of repeated acute and maintenance infusions using a randomized study design.
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Affiliation(s)
- Farhan Fancy
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Sipan Haikazian
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Danica E. Johnson
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - David C. J. Chen-Li
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Anastasia Levinta
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Muhammad I. Husain
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Rodrigo B. Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Joshua D. Rosenblat
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Braxia Scientific, Braxia Health, Canadian Rapid Treatment Centre of Excellence, Mississauga, ON, Canada
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