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Hayley AC, Shiferaw B, Aitken B, Rositano J, Downey LA. Acute methamphetamine and alcohol usage alters gaze behaviour during driving: A randomised, double-blind, placebo-controlled study. J Psychopharmacol 2024; 38:636-646. [PMID: 39068640 PMCID: PMC11290035 DOI: 10.1177/02698811241261024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
BACKGROUND Methamphetamine is frequently co-consumed with alcohol, yet combined effects on visually guided behaviours have not been experimentally assessed. This study examined whether methamphetamine and alcohol-induced changes in gaze behaviour can be accurately detected and indexed during a simulated driving task to establish characteristic patterns relevant to traffic safety. METHODS In a randomised, placebo-controlled, cross-over study design, the effects of acute oral methamphetamine (0.42 mg/kg) were assessed with and without low doses of alcohol (target 0.04% blood alcohol content) on gaze behaviour during driving. Twenty healthy adults (mean age 29.5 years (SD ± 4.9), 40% female) completed four, 1-h simulated drives with simultaneous eye monitoring using the SensoMotoric Instruments cap-mounted eye tracker over a 4-week experimental paradigm. Gaze entropy measures were used to quantify visual scanning efficiency, expressed as gaze transition entropy and stationary gaze entropy. Fixations, recorded as duration (milliseconds, ms) and rate (count) per minute, were examined in 10-min bins over the duration of the drive. Driving performance was assessed by the standard deviation of lateral position, standard deviation of speed and steering variability. RESULTS Methamphetamine increased the rate and duration of fixations and produced a less dispersed but more disorganised pattern of gaze during highway driving while preserving performance. Alcohol alone impaired both oculomotor control and driving performance, even when consumed at levels well below the legal limit stipulated in many international jurisdictions. CONCLUSIONS Methamphetamine-affected drivers display inefficient exploration in a limited visual range during driving. Eye-tracking metrics thus show potential for indexing intoxication due to psychoactive substance usage.
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Affiliation(s)
- Amie C Hayley
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
- Institute for Breathing and Sleep, Austin Hospital, Melbourne, VIC, Australia
- International Council for Alcohol, Drugs and Traffic Safety
| | - Brook Shiferaw
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Blair Aitken
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
| | | | - Luke A Downey
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
- Institute for Breathing and Sleep, Austin Hospital, Melbourne, VIC, Australia
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Manning B, Arkell TR, Hayley AC, Downey LA. A semi-naturalistic open-label study examining the effect of prescribed medical cannabis use on simulated driving performance. J Psychopharmacol 2024; 38:247-257. [PMID: 38332655 PMCID: PMC10944578 DOI: 10.1177/02698811241229524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
BACKGROUND Despite increasing medical cannabis use, research has yet to establish whether and to what extent products containing delta-9-tetrahydrocannabinol (THC) impact driving performance among patients. Stable doses of prescribed cannabinoid products during long-term treatment may alleviate clinical symptoms affecting cognitive and psychomotor performance. AIM To examine the effects of open-label prescribed medical cannabis use on simulated driving performance among patients. METHODS In a semi-naturalistic laboratory study, 40 adults (55% male) aged between 23 and 80 years, consumed their own prescribed medical cannabis product. Driving performance outcomes including standard deviation of lateral position (SDLP), the standard deviation of speed (SDS), mean speed and steering variability were evaluated using the Forum8 driving simulator at baseline (pre-dosing), 2.5 h and 5 -h (post-dosing). Perceived driving effort (PDE) was self-reported after each drive. Oral fluid and whole blood samples were collected at multiple timepoints and analysed for THC via liquid chromatography-mass spectrometry. RESULTS A significant main effect of time was observed for mean speed (p = 0.014) and PDE (p = 0.020), with patients displaying modest stabilisation of vehicle control, increased adherence to speed limits and reductions in PDE post-dosing, relative to baseline. SDLP (p = 0.015) and PDE (p = 0.043) were elevated for those who consumed oil relative to flower-based products. Detectable THC concentrations were observed in oral fluid at 6-h post-dosing (range = 0-24 ng/mL). CONCLUSIONS This semi-naturalistic study suggests that the consumption of medical cannabis containing THC (1.13-39.18 mg/dose) has a negligible impact on driving performance when used as prescribed.
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Affiliation(s)
- Brooke Manning
- Centre for Mental Health and Brain Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Thomas R Arkell
- Centre for Mental Health and Brain Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Amie C Hayley
- Centre for Mental Health and Brain Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia
- Institute for Breathing and Sleep (IBAS), Austin Health, Melbourne, VIC, Australia
| | - Luke A Downey
- Centre for Mental Health and Brain Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia
- Institute for Breathing and Sleep (IBAS), Austin Health, Melbourne, VIC, Australia
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Lucuta L, Maas-Gramlich A, Kraemer M, Andresen-Streichert H, Juebner M. Ketamine in DUID cases in the greater Cologne area. Forensic Sci Int 2024; 354:111905. [PMID: 38064774 DOI: 10.1016/j.forsciint.2023.111905] [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: 08/16/2023] [Revised: 11/20/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Ketamine is primarily used as an anaesthetic or for analgesics in medical treatment, but due to its dissociative and hallucinogenic effects, abuse has increased in the past years leading to several drug impaired driving cases. METHODS Eight DUID (driving under the influence of drugs) cases involving ketamine from two institutes of legal medicine over a period from January 2021 to January 2023 were evaluated. The cases were compared with regard to psychomotor impairments, adverse effects on driving performance and co-consumption of drugs. Analyses of ketamine were carried out by high performance liquid chromatography with diode array detection (HPLC-DAD). Other drugs of abuse were either detected via liquid chromatography with tandem mass spectromety (LC-MS/MS) and/or gas chromatography with (tandem) mass spectrometry (GC-MS(/MS)). RESULTS Ketamine plasma concentrations in a range of approx. 100-1200 ng/mL (mean: 510 ng/mL, median: 370 ng/mL) were detected. Co-consumption of at least one substance was ascertained in all cases. Besides driving impairments, recorded psychomotor impairments of the drivers comprised e.g. dilated pupils, missing or delayed pupil reactions, a slurred or decelerated speech, delayed reaction, lack of concentration, vertigo or agitation. DISCUSSION The observed peculiarities were in-line with literature data. However, the assessment and differentiation of ketamine-induced impairments was aggravated due to co-consumption of other drugs of abuse or pharmaceuticals in the herein investigated cases. Nevertheless, in two cases impairments can be attributed mainly to ketamine consumption since the co-consumed substances were only detected in low concentrations. CONCLUSION The presented cases provide additional data on psychomotor impairments observed in ketamine-related DUID cases. Limiting factors are co-consumption of substances, unknown habituation to drugs and the limited case number. Nevertheless, the results of this study are comparable with existing literature data. Since the abuse of ketamine has increased in the past years, these data will support forensic casework.
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Affiliation(s)
- L Lucuta
- Department of Toxicology, Institute of Legal Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.
| | - A Maas-Gramlich
- Institute of Forensic Medicine, Forensic Toxicology, University Hospital Bonn, Bonn, Germany
| | - M Kraemer
- Institute of Forensic Medicine, Forensic Toxicology, University Hospital Bonn, Bonn, Germany
| | - H Andresen-Streichert
- Department of Toxicology, Institute of Legal Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - M Juebner
- Department of Toxicology, Institute of Legal Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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Aitken B, Hayley AC, Ford TC, Geier L, Shiferaw BA, Downey LA. Driving impairment and altered ocular activity under the effects of alprazolam and alcohol: A randomized, double-blind, placebo-controlled study. Drug Alcohol Depend 2023; 251:110919. [PMID: 37611483 DOI: 10.1016/j.drugalcdep.2023.110919] [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: 04/20/2023] [Revised: 07/03/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Alprazolam, also known by trade-name Xanax, is regularly detected along with alcohol in blood samples of drivers injured or killed in traffic collisions. While their co-consumption is principally legal, policy guidelines concerning fitness-to-drive are lacking and methods to index impairment are underdeveloped. METHODS In this randomized, double-blind, placebo-controlled, crossover trial, we examined whether legally permissible levels of alcohol [target 0.04% blood alcohol concentration (BAC)], alprazolam (1mg), and their combination impacts driving performance, and whether driving impairment can be indexed by ocular activity. Participants completed a test battery consisting of a 40-minute simulated highway drive with ocular parameters assessed simultaneously, the Karolinska Sleepiness Scale, and a confidence to drive assessment following four separate treatment combinations. The predictive efficacy of ocular parameters to identify alcohol and alprazolam-related driving impairment was also examined. RESULTS Among 21 healthy, fully licensed drivers (37% female, mean age 28.43, SD ± 3.96), driving performance was significantly impacted by alprazolam, alcohol, and their combination. Linear regression models revealed that the odds of an out-of-lane event occurring increased five-fold under the influence alprazolam alone and when combined with alcohol. An increase in gaze transition entropy (GTE) demonstrated the strongest association with the odds of an out-of-lane event occurring in the same minute, with both microsleeps and fixation rate achieving moderate accuracy across treatments. CONCLUSIONS Alprazolam and alcohol, alone and in combination, impaired select aspects of vehicle control over time. GTE, microsleeps, and fixation rate show potential as real-time indicators of driving impairment and crash risk associated with alcohol and alprazolam consumption.
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Affiliation(s)
- Blair Aitken
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - Amie C Hayley
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia; Institute for Breathing and Sleep (IBAS), Austin Hospital, Heidelberg, Victoria, Australia
| | - Talitha C Ford
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia; Cognitive Neuroscience Unit, Deakin University, Geelong, Victoria, Australia
| | - Lauren Geier
- Forensic Science South Australia, Adelaide, Australia
| | - Brook A Shiferaw
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia; Institute for Breathing and Sleep (IBAS), Austin Hospital, Heidelberg, Victoria, Australia; Seeing Machines, Fyshwick, Australian Capital Territory (ACT), Australia
| | - Luke A Downey
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia; Institute for Breathing and Sleep (IBAS), Austin Hospital, Heidelberg, Victoria, Australia.
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Manning B, Hayley AC, Catchlove S, Shiferaw B, Stough C, Downey LA. Effect of CannEpil ® on simulated driving performance and co-monitoring of ocular activity: A randomised controlled trial. J Psychopharmacol 2023; 37:472-483. [PMID: 37129083 PMCID: PMC10184186 DOI: 10.1177/02698811231170360] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Medicinal cannabis products containing Δ9-tetrahydrocannabinol (THC) are increasingly accessible. Yet, policy guidelines regarding fitness to drive are lacking, and cannabinoid-specific indexations of impairment are underdeveloped. AIMS To determine the impact of a standardised 1 mL sublingual dose of CannEpil®, a medicinal cannabis oil containing 100 mg cannabidiol (CBD) and 5 mg THC on simulated driving performance, relative to placebo and whether variations in vehicle control can be indexed by ocular activity. METHODS A double-blind, within-subjects, randomised, placebo-controlled, crossover trial assessed 31 healthy fully licensed drivers (15 male, 16 female) aged between 21 and 58 years (M = 38.0, SD = 10.78). Standard deviation of lateral position (SDLP), standard deviation of speed (SDS) and steering variability were assessed over time and as a function of treatment during a 40 min simulated drive, with oculomotor parameters assessed simultaneously. Oral fluid and plasma were collected at 30 min and 2.5 h. RESULTS CannEpil did not significantly alter SDLP across the full drive, although increased SDLP was observed between 20 and 30 min (p < 0.05). CannEpil increased SDS across the full drive (p < 0.05), with variance greatest at 20-30 min (p < 0.001). CannEpil increased fixation duration (p < 0.05), blink rate (trend p = 0.051) and decreased blink duration (p < 0.001) during driving. No significant correlations were observed between biological matrices and performance outcomes. CONCLUSIONS CannEpil impairs select aspects of vehicle control (speed and weaving) over time. Alterations to ocular behaviour suggest that eye tracking may assist in determining cannabis-related driver impairment or intoxication. Australian and New Zealand Clinician Trials Registry, https://anzctr.org.au(ACTRN12619000932167).
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Affiliation(s)
- Brooke Manning
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Amie C Hayley
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
- International Council for Alcohol, Drugs, and Traffic Safety
- Institute for Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
| | - Sarah Catchlove
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Brook Shiferaw
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
- Seeing Machines, Melbourne, VIC, Australia
| | - Con Stough
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Luke A Downey
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
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Effects of psychotropic drugs on ocular parameters relevant to traffic safety: A systematic review. Neurosci Biobehav Rev 2022; 141:104831. [PMID: 35995080 PMCID: PMC10067018 DOI: 10.1016/j.neubiorev.2022.104831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022]
Abstract
Driving is a complex neurobehavioural task necessitating the rapid selection, uptake, and processing of visual information. Eye movements that are critical for the execution of visually guided behaviour such as driving are also sensitive to the effects of psychotropic substances. The Embase (via Ovid), EBSCOHost, Psynet, Pubmed, Scopus and Web of Science databases were examined from January 01st, 2000 to December 31st, 2021. Study selection, data extraction and Cochrane Risk of Bias (RoB2) assessments were conducted according to PRISMA guidelines. The review was prospectively registered (CRD42021267554). In total, 36 full-text articles examined the effects of six principal psychotropic drug classes on measures of oculomotor parameters relevant to driving. Centrally depressing substances affect oculomotor responses in a dose-dependent manner. Psychostimulants improve maximal speed, but not accuracy, of visual search behaviours. Inhaled Δ-9-tetrahydrocannabinol (THC) increases inattention (saccadic inaccuracy) but does not consistently affect other oculomotor parameters. Alterations to composite ocular parameters due to psychoactive substance usage likely differently compromises performance precision during driving through impaired ability to select and process dynamic visual information.
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Su S, Kay G, Hochadel T, Rojo J, Christopher Stein J, Boinpally R, Periclou A. A randomized, multicenter trial assessing the effects of rapastinel compared to ketamine, alprazolam, and placebo on simulated driving performance. Clin Transl Sci 2022; 15:255-266. [PMID: 34423904 PMCID: PMC8742651 DOI: 10.1111/cts.13145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/20/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022] Open
Abstract
N-methyl-D-aspartate ionotropic glutamatergic receptor (NMDAR) modulators, including rapastinel and ketamine, elicit rapid and sustained antidepressant responses in patients with treatment-resistant major depressive disorder. This phase I, randomized, multicenter, placebo-controlled, five-period, crossover, single-dose study evaluated simulated driving performance of healthy participants (N = 107) after single doses of rapastinel slow intravenous (i.v.) bolus 900 and 1800 mg, alprazolam oral 0.75 mg (positive control), ketamine i.v. infusion 0.5 mg/kg (clinical comparator), and placebo ~ 45 min before driving. The primary end point was SD of lateral position (SDLP) during the 60-min 100-km simulated driving scenario. Additional measures of driving performance, sleepiness, and cognition were also evaluated. To assess effects over time, mean SDLP was calculated for each 10-min interval of driving. Sensitivity of the assays was confirmed with alprazolam (all placebo comparisons p < 0.02). Rapastinel 900 and 1800 mg did not significantly affect simulated driving performance compared to placebo (both p > 0.5). Both rapastinel doses resulted in significantly less impaired driving compared to alprazolam or ketamine (all p < 0.002); ketamine significantly impaired driving compared to placebo (p = 0.0001). Results for the additional measures were similar to the primary end point. No new safety signals were observed for any study interventions. This first study of rapastinel effects on simulated driving found that rapastinel 900 and 1800 mg did not impair driving performance, but ketamine 0.5 mg/kg resulted in significantly impaired driving performance. Ketamine's effects on driving were maintained for at least 105 min, indicating that clinicians should be vigilant to prevent or postpone driving in patients after ketamine treatment.
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Affiliation(s)
- Shengfang Su
- Allergan plc (now AbbVie, Inc.)MadisonNew JerseyUSA
| | - Gary Kay
- Cognitive Research CorporationSt. PetersburgFloridaUSA
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Boyd NL, Navathe PD. An Update to Aircrew Grounding Periods After Ketamine Use. Aerosp Med Hum Perform 2021; 92:670-675. [PMID: 34503619 DOI: 10.3357/amhp.5764.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION: Ketamine is a rapidly acting general anesthetic which is globally used in surgical analgesia, as well as in the management of pain. It is also used as a recreational drug. Because of its widespread use in surgical settings, the use of this drug presents an aeromedical problemin addition, of course, to the underlying condition for which it has been used. The literature around the mechanisms and side effects of ketamine is reasonably mature, and it is possible to make fairly dependable risk management decisions about return to flying based on the information available. Accordingly, following ketamine use it is recommended that aviators be grounded for 48 h following Aviation Medical Examiner review. If review is unavailable, the aviator should be grounded for 1 wk to allow sufficient time to identify the existence of prolonged side effects, such as psychomimetic effects or cognitive changes.Boyd NL, Navathe PD. An update to aircrew grounding periods after ketamine use. Aerosp Med Hum Perform. 2021; 92(8):670-675.
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Davis MT, DellaGiogia N, Maruff P, Pietrzak RH, Esterlis I. Acute cognitive effects of single-dose intravenous ketamine in major depressive and posttraumatic stress disorder. Transl Psychiatry 2021; 11:205. [PMID: 33833217 PMCID: PMC8032778 DOI: 10.1038/s41398-021-01327-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/19/2021] [Accepted: 03/17/2021] [Indexed: 02/02/2023] Open
Abstract
Intravenous (IV) subanesthetic doses of ketamine have been shown to reduce psychiatric distress in both major depressive (MDD) and posttraumatic stress disorder (PTSD). However, the effect of ketamine on cognitive function in these disorders is not well understood. To address this gap, we examined the effect of a single dose of IV ketamine on cognition in individuals with MDD and/or PTSD relative to healthy controls (HC). Psychiatric (n = 29; 15 PTSD, 14 MDD) and sex- age- and IQ matched HC (n = 29) groups were recruited from the community. A single subanesthetic dose of IV ketamine was administered. Mood and cognitive measures were collected prior to, 2 h and 1 day post-ketamine administration. MDD/PTSD individuals evidenced a large-magnitude improvement in severity of depressive symptoms at both 2-hours and 1 day post-ketamine administration (p's < .001, Cohen d's = 0.80-1.02). Controlling for baseline performance and years of education, IV ketamine induced declines in attention (ATTN), executive function (EF), and verbal memory (VM) 2 h post-administration, all of which had resolved by 1 day post-ketamine across groups. The magnitude of cognitive decline was significantly larger in MDD/PTSD relative to HC on attention only (p = .012, d = 0.56). Ketamine did not affect working memory (WM) performance. Cognitive function (baseline, change from baseline to post-ketamine) was not associated with antidepressant response to ketamine. Results suggest that while ketamine may have an acute deleterious effect on some cognitive domains in both MDD/PTSD and HC individuals, most notably attention, this reduction is transient and there is no evidence of ketamine-related cognitive dysfunction at 1 day post-administration.
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Affiliation(s)
- Margaret T Davis
- Yale University School of Medicine, Department of Psychiatry, New Haven, USA
- Yale University, Department of Psychology, New Haven, USA
- U.S. Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, Washington, DC, USA
| | - Nicole DellaGiogia
- Yale University School of Medicine, Department of Psychiatry, New Haven, USA
| | | | - Robert H Pietrzak
- Yale University School of Medicine, Department of Psychiatry, New Haven, USA
- U.S. Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, Washington, DC, USA
| | - Irina Esterlis
- Yale University School of Medicine, Department of Psychiatry, New Haven, USA.
- Yale University, Department of Psychology, New Haven, USA.
- U.S. Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, Washington, DC, USA.
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Swainson J, McGirr A, Blier P, Brietzke E, Richard-Devantoy S, Ravindran N, Blier J, Beaulieu S, Frey BN, Kennedy SH, McIntyre RS, Milev RV, Parikh SV, Schaffer A, Taylor VH, Tourjman V, van Ameringen M, Yatham LN, Ravindran AV, Lam RW. The Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Recommendations for the Use of Racemic Ketamine in Adults with Major Depressive Disorder: Recommandations Du Groupe De Travail Du Réseau Canadien Pour Les Traitements De L'humeur Et De L'anxiété (Canmat) Concernant L'utilisation De La Kétamine Racémique Chez Les Adultes Souffrant De Trouble Dépressif Majeur. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:113-125. [PMID: 33174760 PMCID: PMC7918868 DOI: 10.1177/0706743720970860] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Patients with major depressive disorder often have limited response to first-line and second-line medications; hence, novel pharmacological treatments are needed for treatment-resistant depression (TRD). Ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, has demonstrated rapid antidepressant effects in patients with TRD. The Canadian Network for Mood and Anxiety Treatments (CANMAT) convened a task force to review the evidence for efficacy and safety of racemic ketamine and to provide recommendations for its use in clinical practice. METHODS A systematic review was conducted with computerized search of electronic databases up to January 31, 2020 using combinations of search terms, inspection of bibliographies, and review of other ketamine guidelines and consensus statements. The level of evidence and lines of treatment were assigned according to CANMAT criteria. Recommendations were given in question-answer format. RESULTS Intravenous (IV) racemic ketamine given as a single infusion has Level 1 evidence for efficacy in adults with TRD. The evidence for multiple infusions, given as an acute series or as ongoing maintenance treatment, is limited to Level 3. Adverse events associated with ketamine infusions include behavioral (e.g., dissociative symptoms) and physiological (e.g., hypertension) events. There is only Level 3 or 4 evidence for non-IV formulations of racemic ketamine. Consensus recommendations are given for clinical administration of IV ketamine including patient selection, facility and personnel issues, monitoring, and maintaining response. CONCLUSIONS Single-dose IV racemic ketamine is a third-line recommendation for adults with TRD. The need for repeated and maintenance ketamine infusions should be carefully assessed on a case-by-case basis with consideration of potential risks and benefits. Because of limited evidence for efficacy and risk for misuse and diversion, the use of oral and other formulations of racemic ketamine should be limited to specialists with ketamine-prescribing expertise and affiliations with tertiary or specialized centers.
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Affiliation(s)
- Jennifer Swainson
- Department of Psychiatry, 12357University of Alberta, Edmonton, Alberta, Canada
| | - Alexander McGirr
- Department of Psychiatry, 70401University of Calgary, Alberta, Canada
| | - Pierre Blier
- Department of Psychiatry, 12365University of Ottawa, Ontario, Canada
| | - Elisa Brietzke
- Department of Psychiatry, 104820Queen's University, Kingston, Ontario, Canada
| | | | - Nisha Ravindran
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Jean Blier
- Department of Anesthesiology and Pain Medicine, 12365University of Ottawa, Ontario, Canada
| | - Serge Beaulieu
- Department of Psychiatry, 12367McGill University, Montreal, Quebec, Canada
| | - Benicio N Frey
- Department of Psychiatry and Behavioural Neurosciences, 62703McMaster University, Hamilton, Ontario, Canada
| | - Sidney H Kennedy
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Roger S McIntyre
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Roumen V Milev
- Department of Psychiatry, 104820Queen's University, Kingston, Ontario, Canada
| | - Sagar V Parikh
- Department of Psychiatry, 12266University of Michigan, Ann Arbor, Michigan, USA
| | - Ayal Schaffer
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Valerie H Taylor
- Department of Psychiatry, 70401University of Calgary, Alberta, Canada
| | - Valérie Tourjman
- Department of Psychiatry, 12368Université de Montréal, Québec, Canada
| | - Michael van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, 62703McMaster University, Hamilton, Ontario, Canada
| | - Lakshmi N Yatham
- Department of Psychiatry, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Arun V Ravindran
- Department of Psychiatry, 12366University of Toronto, Ontario, Canada
| | - Raymond W Lam
- Department of Psychiatry, 8166University of British Columbia, Vancouver, British Columbia, Canada
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