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Bahji A, Zarate CA, Vazquez GH. Efficacy and safety of racemic ketamine and esketamine for depression: a systematic review and meta-analysis. Expert Opin Drug Saf 2022; 21:853-866. [PMID: 35231204 PMCID: PMC9949988 DOI: 10.1080/14740338.2022.2047928] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Racemic ketamine and esketamine have demonstrated rapid antidepressant effects. We aimed to review the efficacy and safety of racemic and esketamine for depression. RESEARCH DESIGN AND METHODS We conducted a PRISMA-guided review for relevant randomized controlled trials of racemic or esketamine for unipolar or bipolar major depression from database inception through 2021. We conducted random-effects meta-analyses using pooled rate ratios (RRs) and Cohen's standardized mean differences (d) with their 95% confidence intervals (CI). RESULTS We found 36 studies (2903 participants, 57% female, 45.1 +/- 7.0 years). Nine trials used esketamine, while the rest used racemic ketamine. The overall study quality was high. Treatment with any form of ketamine was associated with improved response (RR=2.14; 95% CI, 1.72-2.66; I2=65%), remission (RR=1.64; 95% CI, 1.33-2.02; I2=39%), and depression severity (d=-0.63; 95% CI, -0.80 to -0.45; I2=78%) against placebo. Overall, there was no association between treatment with any form of ketamine and retention in treatment (RR=1.00; 95% CI, 0.99-1.01; I2<1%), dropouts due to adverse events (RR=1.56; 95% CI, 1.00-2.45; I2<1%), or the overall number of adverse events reported per participant (OR=2.14; 95% CI, 0.82-5.60; I2=62%) against placebo. CONCLUSIONS Ketamine and esketamine are effective, safe, and acceptable treatments for individuals living with depression.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada;,British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Carlos A. Zarate
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gustavo H. Vazquez
- Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Bennett R, Yavorsky C, Bravo G. Ketamine for Bipolar Depression: Biochemical, Psychotherapeutic, and Psychedelic Approaches. Front Psychiatry 2022; 13:867484. [PMID: 35859608 PMCID: PMC9289960 DOI: 10.3389/fpsyt.2022.867484] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Bipolar disorder (type 1) is a serious and chronic psychiatric illness that can be difficult to treat. Many bipolar patients have refractory depressive episodes. Racemic ketamine, a glutamate modulator with prominent dissociate and psychedelic properties, has been demonstrated to have rapid acting antidepressant and anti-obsessional effects which may be useful for treating the symptoms of bipolar depression. Most of the existing research literature on unipolar and bipolar depression has looked at racemic ketamine in the sub-psychedelic dose range given by infusion as a stand-alone treatment (without concurrent psychotherapy). This article expands on the existing research by articulating three different paradigms for ketamine treatment: biochemical, psychotherapeutic, and psychedelic. The authors use composite clinical vignettes to illustrate different ways of working with ketamine to treat bipolar depression, and discuss a variety of clinical considerations for using ketamine with this population, including route, dose, frequency, chemical mitigators, and adverse events. Note that the conceptual paradigms could be applied to any ketamine treatment, with broad applicability beyond bipolar treatment.
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Affiliation(s)
| | | | - Gary Bravo
- KRIYA Institute, Berkeley, CA, United States
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Walsh Z, Mollaahmetoglu OM, Rootman J, Golsof S, Keeler J, Marsh B, Nutt DJ, Morgan CJA. Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review. BJPsych Open 2021; 8:e19. [PMID: 35048815 PMCID: PMC8715255 DOI: 10.1192/bjo.2021.1061] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In the past two decades, subanaesthetic doses of ketamine have been demonstrated to have rapid and sustained antidepressant effects, and accumulating research has demonstrated ketamine's therapeutic effects for a range of psychiatric conditions. AIMS In light of these findings surrounding ketamine's psychotherapeutic potential, we systematically review the extant evidence on ketamine's effects in treating mental health disorders. METHOD The systematic review protocol was registered in PROSPERO (identifier CRD42019130636). Human studies investigating the therapeutic effects of ketamine in the treatment of mental health disorders were included. Because of the extensive research in depression, bipolar disorder and suicidal ideation, only systematic reviews and meta-analyses were included. We searched Medline and PsycINFO on 21 October 2020. Risk-of-bias analysis was assessed with the Cochrane Risk of Bias tools and A Measurement Tool to Assess Systematic Reviews (AMSTAR) Checklist. RESULTS We included 83 published reports in the final review: 33 systematic reviews, 29 randomised controlled trials, two randomised trials without placebo, three non-randomised trials with controls, six open-label trials and ten retrospective reviews. The results were presented via narrative synthesis. CONCLUSIONS Systematic reviews and meta-analyses provide support for robust, rapid and transient antidepressant and anti-suicidal effects of ketamine. Evidence for other indications is less robust, but suggests similarly positive and short-lived effects. The conclusions should be interpreted with caution because of the high risk of bias of included studies. Optimal dosing, modes of administration and the most effective forms of adjunctive psychotherapeutic support should be examined further.
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Affiliation(s)
- Zach Walsh
- Department of Psychology, University of British Columbia, Canada
| | | | - Joseph Rootman
- Department of Psychology, University of British Columbia, Canada
| | - Shannon Golsof
- Department of Psychology, University of British Columbia, Canada
| | - Johanna Keeler
- Eating Disorders Research Group, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, UK
| | - Beth Marsh
- Psychopharmacology and Addiction Research Centre, Department of Psychology, University of Exeter, UK; and Clinical Psychopharmacology Unit, Department of Clinical, Educational and Health Psychology, University College London, UK
| | - David J Nutt
- Drug Science, UK; and Neuropsychopharmacology Unit, Division of Psychiatry, Department of Brain Sciences, Imperial College London, UK
| | - Celia J A Morgan
- Psychopharmacology and Addiction Research Centre, Department of Psychology, University of Exeter, UK
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Fava VAR, Sarin LM, Lucchese AC, Del Sant L, Magalhães E, Delfino RS, Tuena MA, Nakahira C, Jackowski AP, Abdo G, Surjan J, Steiglich M, Barbosa MG, Porto JAD, Lacerda ALT, Cogo-Moreira H. The probability of response after each subcutaneous injection of esketamine in treatment-resistant depression. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2021; 14:212-217. [PMID: 34861929 DOI: 10.1016/j.rpsmen.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The administration of multiple esketamine doses has shown efficacy for unipolar and bipolar treatment-resistant depression (TRD). Nevertheless, the probability of responding or not after each dose in the real-world remains unknown. This study aimed to estimate it throughout four doses of esketamine, administrated via subcutaneous (SC). MATERIAL AND METHODS We conducted a retrospective analysis of a case series of 70 patients with TRD who received treatment from the esketamine assistance program at Federal University of Sao Paulo, between April 2017 and December 2018. The SC injections were administrated weekly at a dose of 0.5-1.0mg/kg, in conjunction with patients' psychotropic drugs. Response was defined as a decrease of at least 50% in the Montgomery-Åsberg Depression Rating Scale between baseline and 24h after dose. We used hidden Markov modeling in order to estimate de probability of response after each esketamine injection. RESULTS The probability of a patient that was a "non-responder" to become a "responder" following a SC injection of esketamine was 17.30% and the probability that this patient remains a "non-responder" was 82.70%. The probability of a patient that was a "responder" to remain as a "responder" was 95%. CONCLUSIONS Patients with TRD who had not responded after the first dose of esketamine, still had a chance of responding after the subsequent dose administrated via SC.
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Affiliation(s)
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ana Cecília Lucchese
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Lorena Del Sant
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Magalhães
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Simonini Delfino
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Andrea Parolin Jackowski
- LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Abdo
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Steiglich
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - José Alberto Del Porto
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; School of Public Health, University of Hong Kong, Hong Kong, SAR, China.
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Dean RL, Marquardt T, Hurducas C, Spyridi S, Barnes A, Smith R, Cowen PJ, McShane R, Hawton K, Malhi GS, Geddes J, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with bipolar disorder. Cochrane Database Syst Rev 2021; 10:CD011611. [PMID: 34623633 PMCID: PMC8499740 DOI: 10.1002/14651858.cd011611.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Glutamergic system dysfunction has been implicated in the pathophysiology of bipolar depression. This is an update of the 2015 Cochrane Review for the use of glutamate receptor modulators for depression in bipolar disorder. OBJECTIVES 1. To assess the effects of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with bipolar disorder. 2. To review the acceptability of ketamine and other glutamate receptor modulators in people with bipolar disorder who are experiencing depressive symptoms. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA RCTs comparing ketamine or other glutamate receptor modulators with other active psychotropic drugs or saline placebo in adults with bipolar depression. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. Primary outcomes were response rate and adverse events. Secondary outcomes included remission rate, depression severity change scores, suicidality, cognition, quality of life, and dropout rate. The GRADE framework was used to assess the certainty of the evidence. MAIN RESULTS Ten studies (647 participants) were included in this review (an additional five studies compared to the 2015 review). There were no additional studies added to the comparisons identified in the 2015 Cochrane review on ketamine, memantine and cytidine versus placebo. However, three new comparisons were found: ketamine versus midazolam, N-acetylcysteine versus placebo, and riluzole versus placebo. The glutamate receptor modulators studied were ketamine (three trials), memantine (two), cytidine (one), N-acetylcysteine (three), and riluzole (one). Eight of these studies were placebo-controlled and two-armed. In seven trials the glutamate receptor modulators had been used as add-on drugs to mood stabilisers. Only one trial compared ketamine with an active comparator, midazolam. The treatment period ranged from a single intravenous administration (all ketamine studies), to repeated administration for riluzole, memantine, cytidine, and N-acetylcysteine (with a follow-up of eight weeks, 8 to 12 weeks, 12 weeks, and 16 to 20 weeks, respectively). Six of the studies included sites in the USA, one in Taiwan, one in Denmark, one in Australia, and in one study the location was unclear. All participants had a primary diagnosis of bipolar disorder and were experiencing an acute bipolar depressive episode, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition (IV) or fourth edition text revision (IV-TR). Among all glutamate receptor modulators included in this review, only ketamine appeared to be more efficacious than placebo 24 hours after infusion for response rate (odds ratio (OR) 11.61, 95% confidence interval (CI) 1.25 to 107.74; P = 0.03; participants = 33; studies = 2; I² = 0%, low-certainty evidence). Ketamine seemed to be more effective in reducing depression rating scale scores (MD -11.81, 95% CI -20.01 to -3.61; P = 0.005; participants = 32; studies = 2; I2 = 0%, very low-certainty evidence). There was no evidence of ketamine's efficacy in producing remission over placebo at 24 hours (OR 5.16, 95% CI 0.51 to 52.30; P = 0.72; participants = 33; studies = 2; I2 = 0%, very low-certainty evidence). Evidence on response, remission or depression rating scale scores between ketamine and midazolam was uncertain at 24 hours due to very low-certainty evidence (OR 3.20, 95% CI 0.23 to 45.19). In the one trial assessing ketamine and midazolam, there were no dropouts due to adverse effects or for any reason (very low-certainty evidence). Placebo may have been more effective than N-acetylcysteine in reducing depression rating scale scores at three months, although this was based on very low-certainty evidence (MD 1.28, 95% CI 0.24 to 2.31; participants = 58; studies = 2). Very uncertain evidence found no difference in response at three months (OR 0.82, 95% CI 0.32 to 2.14; participants = 69; studies = 2; very low-certainty evidence). No data were available for remission or acceptability. Extremely limited data were available for riluzole vs placebo, finding only very-low certainty evidence of no difference in dropout rates (OR 2.00, 95% CI 0.31 to 12.84; P = 0.46; participants = 19; studies = 1; I2 = 0%). AUTHORS' CONCLUSIONS It is difficult to draw reliable conclusions from this review due to the certainty of the evidence being low to very low, and the relatively small amount of data usable for analysis in bipolar disorder, which is considerably less than the information available for unipolar depression. Nevertheless, we found uncertain evidence in favour of a single intravenous dose of ketamine (as add-on therapy to mood stabilisers) over placebo in terms of response rate up to 24 hours, however ketamine did not show any better efficacy for remission in bipolar depression. Even though ketamine has the potential to have a rapid and transient antidepressant effect, the efficacy of a single intravenous dose may be limited. We did not find conclusive evidence on adverse events with ketamine, and there was insufficient evidence to draw meaningful conclusions for the remaining glutamate receptor modulators. However, ketamine's psychotomimetic effects (such as delusions or delirium) may have compromised study blinding in some studies, and so we cannot rule out the potential bias introduced by inadequate blinding procedures. To draw more robust conclusions, further methodologically sound RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine, and to study different methods of sustaining antidepressant response, such as repeated administrations.
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Affiliation(s)
| | | | | | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | | | | | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rupert McShane
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, Australia
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Bahji A, Zarate CA, Vazquez GH. Ketamine for Bipolar Depression: A Systematic Review. Int J Neuropsychopharmacol 2021; 24:535-541. [PMID: 33929489 PMCID: PMC8299822 DOI: 10.1093/ijnp/pyab023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/12/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Ketamine appears to have a therapeutic role in certain mental disorders, most notably unipolar major depressive disorder. However, its efficacy in bipolar depression is less clear. This study aimed to assess the efficacy and tolerability of ketamine for bipolar depression. METHODS We conducted a systematic review of experimental studies using ketamine for the treatment of bipolar depression. We searched PubMed, MEDLINE, Embase, PsycINFO, and the Cochrane Central Register for relevant studies published since each database's inception. We synthesized evidence regarding efficacy (improvement in depression rating scores) and tolerability (adverse events, dissociation, dropouts) across studies. RESULTS We identified 6 studies, with 135 participants (53% female; 44.7 years; standard deviation, 11.7 years). All studies used 0.5 mg/kg of add-on intravenous racemic ketamine, with the number of doses ranging from 1 to 6; all participants continued a mood-stabilizing agent. The overall proportion achieving a response (defined as those having a reduction in their baseline depression severity of at least 50%) was 61% for those receiving ketamine and 5% for those receiving a placebo. The overall response rates varied from 52% to 80% across studies. Ketamine was reasonably well tolerated; however, 2 participants (1 receiving ketamine and 1 receiving placebo) developed manic symptoms. Some participants developed significant dissociative symptoms at the 40-minute mark following ketamine infusion in 2 trials. CONCLUSIONS There is some preliminary evidence supporting use of intravenous racemic ketamine to treat adults with bipolar depression. There is a need for additional studies exploring longer-term outcomes and alterative formulations of ketamine.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada; British Columbia Centre for Substance Use, Vancouver, British Columbia, Canada; Research in Addiction Medicine Scholars [RAMS] Program, Boston University Medical Centre, Boston, MA, USA
| | - Carlos A Zarate
- Section Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland, USA
| | - Gustavo H Vazquez
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada,Correspondence: Gustavo Vazquez, MD, PhD, FRCPC, Professor of Psychiatry, Queen’s University Medical School, 752 King Street West, Kingston, ON K7L 4X3, Canada ()
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Comparative efficacy of racemic ketamine and esketamine for depression: A systematic review and meta-analysis. J Affect Disord 2021; 278:542-555. [PMID: 33022440 PMCID: PMC7704936 DOI: 10.1016/j.jad.2020.09.071] [Citation(s) in RCA: 174] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ketamine appears to have a therapeutic role in certain mental disorders, most notably depression. However, the comparative performance of different formulations of ketamine is less clear. OBJECTIVES This study aimed to assess the comparative efficacy and tolerability of racemic and esketamine for the treatment of unipolar and bipolar major depression. DESIGN Systematic review and meta-analysis. DATA SOURCES We searched PubMed, MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Clinical Trials, and the Cochrane Database of Systematic Reviews for relevant studies published since database inception and December 17, 2019. STUDY ELIGIBILITY CRITERIA We considered randomized controlled trials examining racemic or esketamine for the treatment of unipolar or bipolar major depression. OUTCOMES Primary outcomes were response and remission from depression, change in depression severity, suicidality, retention in treatment, drop-outs, and drop-outs due to adverse events. ANALYSIS Evidence from randomized controlled trials was synthesized as rate ratios (RRs) for treatment response, disorder remission, adverse events, and withdrawals and as standardized mean differences (SMDs) for change in symptoms, via random-effects meta-analyses. FINDINGS 24 trials representing 1877 participants were pooled. Racemic ketamine relative to esketamine demonstrated greater overall response (RR = 3.01 vs. RR = 1.38) and remission rates (RR = 3.70 vs. RR = 1.47), as well as lower dropouts (RR = 0.76 vs. RR = 1.37). CONCLUSIONS Intravenous ketamine appears to be more efficacious than intranasal esketamine for the treatment of depression.
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Fava VAR, Sarin LM, Lucchese AC, Del Sant L, Magalhães E, Delfino RS, Tuena MA, Nakahira C, Jackowski AP, Abdo G, Surjan J, Steiglich M, Barbosa MG, Porto JAD, Lacerda ALT, Cogo-Moreira H. The probability of response after each subcutaneous injection of esketamine in treatment-resistant depression. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2020; 14:S1888-9891(20)30117-8. [PMID: 33075541 DOI: 10.1016/j.rpsm.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/12/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The administration of multiple esketamine doses has shown efficacy for unipolar and bipolar treatment-resistant depression (TRD). Nevertheless, the probability of responding or not after each dose in the real-world remains unknown. This study aimed to estimate it throughout four doses of esketamine, administrated via subcutaneous (SC). MATERIAL AND METHODS We conducted a retrospective analysis of a case series of 70 patients with TRD who received treatment from the esketamine assistance program at Federal University of Sao Paulo, between April 2017 and December 2018. The SC injections were administrated weekly at a dose of 0.5-1.0mg/kg, in conjunction with patients' psychotropic drugs. Response was defined as a decrease of at least 50% in the Montgomery-Åsberg Depression Rating Scale between baseline and 24h after dose. We used hidden Markov modeling in order to estimate de probability of response after each esketamine injection. RESULTS The probability of a patient that was a "non-responder" to become a "responder" following a SC injection of esketamine was 17.30% and the probability that this patient remains a "non-responder" was 82.70%. The probability of a patient that was a "responder" to remain as a "responder" was 95%. CONCLUSIONS Patients with TRD who had not responded after the first dose of esketamine, still had a chance of responding after the subsequent dose administrated via SC.
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Affiliation(s)
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ana Cecília Lucchese
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Lorena Del Sant
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Magalhães
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Simonini Delfino
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Andrea Parolin Jackowski
- LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Abdo
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Steiglich
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - José Alberto Del Porto
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; School of Public Health, University of Hong Kong, Hong Kong, SAR, China.
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10
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Dome P, Rihmer Z, Gonda X. Suicide Risk in Bipolar Disorder: A Brief Review. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E403. [PMID: 31344941 PMCID: PMC6723289 DOI: 10.3390/medicina55080403] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/15/2019] [Accepted: 07/23/2019] [Indexed: 12/19/2022]
Abstract
Bipolar disorders (BDs) are prevalent mental health illnesses that affect about 1-5% of the total population, have a chronic course and are associated with a markedly elevated premature mortality. One of the contributors for the decreased life expectancy in BD is suicide. Accordingly, the rate of suicide among BD patients is approximately 10-30 times higher than the corresponding rate in the general population. Extant research found that up to 20% of (mostly untreated) BD subjects end their life by suicide, and 20-60% of them attempt suicide at least one in their lifetime. In our paper we briefly recapitulate the current knowledge on the epidemiological aspects of suicide in BD as well as factors associated with suicidal risk in BD. Furthermore, we also discuss concisely the possible means of suicide prevention in BD.
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Affiliation(s)
- Peter Dome
- Department of Psychiatry and Psychotherapy, Semmelweis University, Faculty of Medicine, 1125 Budapest, Hungary.
- National Institute of Psychiatry and Addictions, Laboratory for Suicide Research and Prevention, 1135 Budapest, Hungary.
| | - Zoltan Rihmer
- Department of Psychiatry and Psychotherapy, Semmelweis University, Faculty of Medicine, 1125 Budapest, Hungary
- National Institute of Psychiatry and Addictions, Laboratory for Suicide Research and Prevention, 1135 Budapest, Hungary
| | - Xenia Gonda
- Department of Psychiatry and Psychotherapy, Semmelweis University, Faculty of Medicine, 1125 Budapest, Hungary
- National Institute of Psychiatry and Addictions, Laboratory for Suicide Research and Prevention, 1135 Budapest, Hungary
- MTA-SE Neuropsychopharmacology, Neurochemistry Research Group, Hungarian Academy of Sciences, 1089 Budapest, Hungary
- NAP-2-SE New Antidepressant Target Research Group, Hungarian Brain Research Program, Semmelweis University, 1089 Budapest, Hungary
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Revista Digital Internacional de Psicología y Ciencia Social | Volumen 5 | Número 1 | Enero-Junio 2019 | Los campos transdisciplinares de la psicología. REVISTA DIGITAL INTERNACIONAL DE PSICOLOGÍA Y CIENCIA SOCIAL 2019. [DOI: 10.22402/j.rdipycs.unam.5.1.2019.218.1-148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Hablar de psicología y ciencia social es hablar de un amplio campo de aplicaciones de técnicasy conocimientos, así como el uso de distintas habilidades y recursos con un objetivo en común: ampliar el campo de conocimiento de los individuos y de la sociedad.Si bien se ha discutido mucho acerca de los términos que se refieren a este tipo de trabajo, para lograr este objetivo hoy existen varias disciplinas que se encargande investigar diversas problemáticas y temas de interés; sin embargo, aunque cada una de esas profesiones tiene sus principios para hacerlo, éstas pueden trabajar en conjunto con un interés en común; esta investigación es lo que conocemos como investigación transdisciplinaria, y no es sólo la investigación que se efectúa en conjunto respecto a una problemática en común.Este trabajo conjunto responde a las demandas que se presentan en la sociedad actual en que vivimos, donde se ha visto que en los últimos años se han reunido profesionales para investigar problemáticas desde distintos puntos de vista y que en algún punto ha surgido la necesidad de complementarse entre sí. Dicho trabajo corresponde también a la apertura que se ha tenido de otras profesiones de requerir ese trabajo con otros profesionales para explicar algunas problemáticas y que no sólo terminará enriqueciendo en conocimiento e investigaciones, sino en una experiencia profesional importante basada en comunicación, responsabilidades y ética.
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Intervención psicofisiológica para el manejo afectivo de una paciente con trastorno depresivo bipolar-II. REVISTA DIGITAL INTERNACIONAL DE PSICOLOGÍA Y CIENCIA SOCIAL 2019. [DOI: 10.22402/j.rdipycs.unam.5.1.2019.182.96-111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Se presenta el caso de una paciente femenina de 25 años de edad, soltera, con problemas de pareja y diagnóstico depresivo bipolar tipo II. Para el manejo afectivo de su depresión se utilizaron estrategias de intervención psicofisiológicas que regularan la actividad autonómica subyacente al nivel de estrés, ansiedad y depresión, así como la promoción del lenguaje afectivo mediante la escritura emocional autorreflexiva, y estrategias cognitivo-conductuales como entrenamiento asertivo, solución de problemas y activación conductual. Los resultados de regulación autonómica muestran cambios clínicos en la temperatura periférica en manos para el manejo de estrés; un decremento en la tasa respiratoria cuando la paciente logra expresar su lenguaje afectivo de manera asertiva e incremento de lenguaje propositivo. Los índices psicométricos de ansiedad y depresión disminuyeron clínicamente. Se concluye que el manejo psicofisiológico es útil para regular el estado afectivo negativo y se propone ampliar su manejo posterior con estrategias de aceptación y compromiso.
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Kheirabadi G, Vafaie M, Kheirabadi D, Mirlouhi Z, Hajiannasab R. Comparative Effect of Intravenous Ketamine and Electroconvulsive Therapy in Major Depression: A Randomized Controlled Trial. Adv Biomed Res 2019; 8:25. [PMID: 31123668 PMCID: PMC6477832 DOI: 10.4103/abr.abr_166_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Achieving a rapid onset and durable methods of treatment for major depressive disorders is an issue pursuing in psychiatry. This study was designed to assess the therapeutic efficacy of intravenous (IV) ketamine injection in controlling depressive symptoms in comparison with electroconvulsive therapy (ECT) in major depressed disordered patients. Materials and Methods Thirty-two patients over 18 years of age who were candidates for ECT were enrolled in the study. They were allocated into two groups using block design randomization. Sixteen patients received IV infusion of 0.5-mg/kg ketamine and 16 patients underwent a bitemporal ECT. To evaluate the changes in depression severity, researchers administered Hamilton Depression Rating Scale (HDRS) at baseline, before each treatment session, and four time points posttreatment (week 1 and months 1, 2, and 3). The Wechsler Memory Scale was used to evaluate the cognitive state of patients in week 1, month 1, and month 3 of the treatment. Results The HDRS showed improvement in depressive symptoms in both the groups with no statistically significant difference. Cognitive state was more favorable (but not significant) in the ketamine group (P > 0.5). Conclusion Treatment with IV ketamine in depressed people has the same antidepressant effects as ECT treatment without any memory deficiency.
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Affiliation(s)
- Gholamreza Kheirabadi
- Department of Psychiatry, School of Medicine, Behavioral Sciences Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Vafaie
- Department of Psychiatry, School of Medicine, Behavioral Sciences Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Dorna Kheirabadi
- Department of psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Mirlouhi
- Department of Psychiatry, School of Medicine, Behavioral Sciences Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasam Hajiannasab
- School of Medicine, Azad University of Iran, Najafabad Unite, Najafabad, Iran
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Neurochemical models of near-death experiences: A large-scale study based on the semantic similarity of written reports. Conscious Cogn 2019; 69:52-69. [PMID: 30711788 DOI: 10.1016/j.concog.2019.01.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 11/20/2022]
Abstract
The real or perceived proximity to death often results in a non-ordinary state of consciousness characterized by phenomenological features such as the perception of leaving the body boundaries, feelings of peace, bliss and timelessness, life review, the sensation of traveling through a tunnel and an irreversible threshold. Near-death experiences (NDEs) are comparable among individuals of different cultures, suggesting an underlying neurobiological mechanism. Anecdotal accounts of the similarity between NDEs and certain drug-induced altered states of consciousness prompted us to perform a large-scale comparative analysis of these experiences. After assessing the semantic similarity between ≈15,000 reports linked to the use of 165 psychoactive substances and 625 NDE narratives, we determined that the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine consistently resulted in reports most similar to those associated with NDEs. Ketamine was followed by Salvia divinorum (a plant containing a potent and selective κ receptor agonist) and a series of serotonergic psychedelics, including the endogenous serotonin 2A receptor agonist N,N-Dimethyltryptamine (DMT). This similarity was driven by semantic concepts related to consciousness of the self and the environment, but also by those associated with the therapeutic, ceremonial and religious aspects of drug use. Our analysis sheds light on the long-standing link between certain drugs and the experience of "dying", suggests that ketamine could be used as a safe and reversible experimental model for NDE phenomenology, and supports the speculation that endogenous NMDA antagonists with neuroprotective properties may be released in the proximity of death.
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Barriers to complete recovery of major depression: cross-sectional, multi-centre study on clinical practice. RECORD study. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2018; 12:141-150. [PMID: 30429067 DOI: 10.1016/j.rpsm.2018.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION To identify barriers to complete recovery in patients suffering from major depressive disorder. METHODS A total of 461 psychiatrists participated in a cross-sectional, non-randomised, qualitative and multi-centre study based on a survey. The study questionnaire included 42 ítems related to management, prevalence, patient profile, impact of residual symptoms, barriers to full recovery, and strategies to increase complete recovery. RESULTS Complete recovery was defined by 86% of participants as complete remission of symptoms plus functional recovery. A total of 83.4% of participants considered that sick leave usually lasted more than 4 months. Seventy-five percent stated that residual symptoms were the main reason for prolongation of sick leave, and 62% that between 26%-50% of patients complained of residual symptoms. Poor compliance with treatment was the most important barrier to complete recovery, followed by a lack of patient cooperation, late beginning of treatment, partial response to antidepressants, and low doses of antidepressant medication. In the case of partial response, 71.8% of participants chose to increase the dose of current treatment, and in the case of lack of response, 72.7% would switch to another antidepressant, and 22.8% would use the combination of two antidepressants, in which case 85.2% would choose agents with complementary mechanisms of action. Forty-nine percent of participants would recommend standard cognitive-behavioural psychotherapy for patients without complete response. CONCLUSIONS Some 50% of patients did not achieve complete remission, frequently related to persistence of residual symptoms. Achievement of complete recovery should be an essential objective.
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Ketamine and depression. Br J Anaesth 2018; 121:1198-1202. [PMID: 30442244 DOI: 10.1016/j.bja.2018.08.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/26/2018] [Accepted: 08/28/2018] [Indexed: 11/21/2022] Open
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Makunts T, Cohen IV, Lee KC, Abagyan R. Population scale retrospective analysis reveals distinctive antidepressant and anxiolytic effects of diclofenac, ketoprofen and naproxen in patients with pain. PLoS One 2018; 13:e0195521. [PMID: 29668764 PMCID: PMC5905979 DOI: 10.1371/journal.pone.0195521] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/23/2018] [Indexed: 12/28/2022] Open
Abstract
Currently approved monoamine modulating antidepressant and anxiolytic pharmaceutics fail in over one third of patients due to delayed and variable therapeutic effect, adverse reactions preceding the therapeutic action, and adherence issues. Even with adequate adherence to the regimen and tolerability, one third of the patients do not respond to any class of antidepressants. There is a strong correlation between treatment resistant depression and increase in inflammatory cytokines in plasma and cerebrospinal fluid. Furthermore, epidemiological studies suggest that depression and anxiety are commonly comorbid with pain and inflammation. While a link between pain, inflammation and depression has been suggested it remains unclear which anti-inflammatory treatment may be beneficial to patients with depression and anxiety due to pain. Here, we analyzed 430,783 FDA adverse effect reports of patients treated for pain to identify potential antidepressant and anxiolytic effects of various anti-inflammatory medications. Patients treated for depression or patients taking any known antidepressants were excluded. The odds ratio analysis of 139,072 NSAID reports revealed that ketoprofen was associated with decreased reports of depression by a factor of 2.32 (OR 0.43 and 95% Confidence Interval [0.31, 0.59]) and decreased reports of anxiety by a factor of 2.86 (OR 0.35 [0.22, 0.56]), diclofenac with decreased depression reports by a factor of 2.22 (OR 0.45 [0.40, 0.49]) and anxiety by a factor of 2.13 (OR 0.47 [0.41, 0.54]), while naproxen decreased depression reports by a factor of 1.92 (OR 0.52 [0.49, 0.57]) and anxiety by a factor of 1.23 (OR 0.81 [0.75, 0.88]). Other NSAIDs did not exhibit any noticeable antidepressant and/or anxiolytic effect.
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Affiliation(s)
- Tigran Makunts
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Isaac V. Cohen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Kelly C. Lee
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Ruben Abagyan
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, United States of America
- * E-mail:
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Population scale data reveals the antidepressant effects of ketamine and other therapeutics approved for non-psychiatric indications. Sci Rep 2017; 7:1450. [PMID: 28469132 PMCID: PMC5431207 DOI: 10.1038/s41598-017-01590-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/31/2017] [Indexed: 12/28/2022] Open
Abstract
Current therapeutic approaches to depression fail for millions of patients due to lag in clinical response and non-adherence. Here we provide new support for the antidepressant effect of an anesthetic drug, ketamine, by Inverse-Frequency Analysis of eight million reports from the FDA Adverse Effect Reporting System. The results of the examination of population scale data revealed that patients who received ketamine had significantly lower frequency of reports of depression than patients who took any other combination of drugs for pain. The analysis also revealed that patients who took ketamine had significantly lower frequency of reports of pain and opioid induced side effects, implying ketamine's potential to act as a beneficial adjunct agent in pain management pharmacotherapy. Further, the Inverse-Frequency Analysis methodology provides robust statistical support for the antidepressant action of other currently approved therapeutics including diclofenac and minocycline.
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