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Mathai DS, Hull TD, Vando L, Malgaroli M. At-home, telehealth-supported ketamine treatment for depression: Findings from longitudinal, machine learning and symptom network analysis of real-world data. J Affect Disord 2024; 361:198-208. [PMID: 38810787 DOI: 10.1016/j.jad.2024.05.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/30/2024] [Accepted: 05/25/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Improving safe and effective access to ketamine therapy is of high priority given the growing burden of mental illness. Telehealth-supported administration of sublingual ketamine is being explored toward this goal. METHODS In this longitudinal study, moderately-to-severely depressed patients received four doses of ketamine at home over four weeks within a supportive digital health context. Treatment was structured to resemble methods of therapeutic psychedelic trials. Patients receiving a second course of treatment were also examined. Symptoms were assessed using the Patient Health Questionnaire (PHQ-9) for depression. We conducted preregistered machine learning and symptom network analyses to investigate outcomes (osf.io/v2rpx). RESULTS A sample of 11,441 patients was analyzed, demonstrating a modal antidepressant response from both non-severe (n = 6384, 55.8 %) and severe (n = 2070, 18.1 %) baseline depression levels. Adverse events were detected in 3.0-4.8 % of participants and predominantly neurologic or psychiatric in nature. A second course of treatment helped extend improvements in patients who responded favorably to initial treatment. Improvement was most strongly predicted by lower depression scores and age at baseline. Symptoms of Depressed mood and Anhedonia sustained depression despite ongoing treatment. LIMITATIONS This study was limited by the absence of comparison or control groups and lack of a fixed-dose procedure for ketamine administration. CONCLUSIONS At-home, telehealth-supported ketamine administration was largely safe, well-tolerated, and associated with improvement in patients with depression. Strategies for combining psychedelic-oriented therapies with rigorous telehealth models, as explored here, may uniquely address barriers to mental health treatment.
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Affiliation(s)
- David S Mathai
- The Johns Hopkins University School of Medicine, Center for Psychedelic and Consciousness Research, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, United States of America; Sattva Medicine - Psychiatry/Psychotherapy Practice, Miami, FL, United States of America
| | - Thomas D Hull
- Institute for Psycholinguistics and Digital Health, United States of America
| | | | - Matteo Malgaroli
- NYU Grossman School of Medicine, Department of Psychiatry, New York, NY, United States of America.
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Mathai DS, Hilbert S, Sepeda ND, Strickland JC, Griffiths RR, Garcia-Romeu A. Double-Blind Comparison of the Two Hallucinogens Dextromethorphan and Psilocybin: Experience-Dependent and Enduring Psychological Effects in Healthy Volunteers. PSYCHEDELIC MEDICINE (NEW ROCHELLE, N.Y.) 2023; 1:241-252. [PMID: 38152462 PMCID: PMC10750378 DOI: 10.1089/psymed.2023.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Rationale N-methyl-D-aspartate receptor-mediated dissociatives and serotonergic hallucinogens are being increasingly used in therapeutic interventions that involve nonordinary states of consciousness and may represent a unique mental health paradigm wherein pharmacologically induced experiences are conducive to psychological well-being. Objective The aim of this study was to further understand how the phenomenological and health-promoting effects of high-dose dextromethorphan (DXM) compared to psilocybin in the same participants when administered under experimental conditions that are typical of therapeutic psychedelic trials. Methods Single, acute oral doses of DXM (400 mg/70 kg), psilocybin (10, 20, 30 mg/70 kg), and inactive placebo were administered under double-blind and psychologically supportive conditions to 20 healthy participants with histories of hallucinogen use. Ratings of personal meaning, spiritual significance, psychological challenge, and psychological insight attributed to acute drug experiences were assessed 7 h (at session end) and 1 week after each drug administration. Persisting psychological effects were assessed 1 week after each drug administration. Results High-dose DXM and psilocybin produced similar increases over placebo in ratings of drug experience that was predictive of psychological benefit at 1 week, even when expectancy effects were minimized. These effects tended to favor psilocybin in a dose-dependent manner and were limited by poor physical tolerability for DXM. Conclusions This analysis suggests the utility of exploring clinical applications of dissociatives that occur within the supportive contexts that are characteristic of psychedelic research and that prioritize the optimization of psychologically valuable drug experiences. This study was registered with ClinicalTrials.gov (NCT02033707).
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Affiliation(s)
- David S. Mathai
- Department of Psychiatry and Behavioral Sciences, Center for Psychedelic and Consciousness Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samantha Hilbert
- Department of Psychiatry and Behavioral Sciences, Center for Psychedelic and Consciousness Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nathan D. Sepeda
- Department of Psychiatry and Behavioral Sciences, Center for Psychedelic and Consciousness Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Psychedelic Drug Research and Education, College of Social Work, The Ohio State University, Columbus, Ohio, USA
| | - Justin C. Strickland
- Department of Psychiatry and Behavioral Sciences, Center for Psychedelic and Consciousness Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Roland R. Griffiths
- Department of Psychiatry and Behavioral Sciences, Center for Psychedelic and Consciousness Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Neuroscience, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert Garcia-Romeu
- Department of Psychiatry and Behavioral Sciences, Center for Psychedelic and Consciousness Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Skala K, Doganay K, Eder H, Mairhofer D, Neubacher K, Plener PL. Intranasal esketamine as therapeutic option: a case report of an adolescent with treatment resistant depression. Front Psychiatry 2023; 14:1118737. [PMID: 37333918 PMCID: PMC10272606 DOI: 10.3389/fpsyt.2023.1118737] [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: 12/07/2022] [Accepted: 05/10/2023] [Indexed: 06/20/2023] Open
Abstract
Depression is among the most common mental health disorders worldwide and treatment resistant depression (TRD) represents a major challenge for both patients and clinicians. In recent years ketamine has received attention as an antidepressant agent, demonstrating promising results in TRD in adults. To date, few attempts have been made in treating adolescent TRD with ketamine and none have used intranasal application. This paper discusses a case of a 17-year-old female adolescent suffering from TRD who underwent treatment with intranasal esketamine application (Spravato 28 mg). As symptoms showed clinically insignificant improvement despite modest gains in objective assessments (GAF, CGI, MADRS), treatment was prematurely discontinued. However, the treatment was tolerable and side effects were scarce and mild. Although this case report does not demonstrate clinical effectiveness, ketamine may nonetheless be a promising substance in treating TRD in other adolescents. Questions regarding the safety of ketamine use in the rapidly developing brains of adolescents still remain unanswered. To further explore the potential benefits of this treatment method a short term RCTs for adolescents with TRD is recommended.
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Affiliation(s)
- Katrin Skala
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Kamer Doganay
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Harald Eder
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Dunja Mairhofer
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Katrin Neubacher
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Paul L. Plener
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany
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Reconsidering "dissociation" as a predictor of antidepressant efficacy for esketamine. Psychopharmacology (Berl) 2023; 240:827-836. [PMID: 36729145 DOI: 10.1007/s00213-023-06324-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/20/2023] [Indexed: 02/03/2023]
Abstract
RATIONALE The relationship between subjective drug experience and antidepressant outcomes for ketamine derivatives is poorly understood but of high clinical relevance. Esketamine is the patented (S)-enantiomer of ketamine and has regulatory approval for psychiatric applications. OBJECTIVES We examined the relationship between acute dissociation, as measured by the Clinician-Administered Dissociative States Scale (CADSS), and antidepressant efficacy, as measured by the Montgomery-Åsberg Depression Rating Scale (MADRS), for esketamine across the 4-week induction phase of treatment. METHODS This post hoc analysis combined data (N = 576) from the TRANSFORM-1 and TRANSFORM-2 clinical trials of esketamine for treatment-resistant depression. Linear mixed models were performed using total MADRS score as the outcome variable with the following independent variables: baseline MADRS score, treatment condition × time interaction, and CADSS × time interaction. To assess whether initial dissociation predicted rapid antidepressant benefit with esketamine, a separately planned regression was performed with day 2 MADRS as the outcome variable with the following dependent variables: baseline MADRS, treatment condition, and day 1 CADSS. RESULTS The linear mixed model did not show any effect of a CADSS × time interaction (p = 0.7). Looking solely at the effect of day 1 CADSS on day 2 MADRS revealed that each additional CADSS point was associated with a - .04 [95% CI - .08, - .002] (p = .04) decrease in MADRS score. CONCLUSIONS We found no evidence of a clinically significant positive or negative association between dissociation and antidepressant effect for esketamine. Our findings suggest that subsequent inquiry in this area will benefit from improved characterization of drug experiences relevant to therapeutic outcomes.
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Wolfson PE, Andries J, Ahlers D, Whippo M. Ketamine-assisted psychotherapy in adolescents with multiple psychiatric diagnoses. Front Psychiatry 2023; 14:1141988. [PMID: 37065886 PMCID: PMC10098148 DOI: 10.3389/fpsyt.2023.1141988] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/28/2023] [Indexed: 04/18/2023] Open
Abstract
Ketamine-assisted psychotherapy is a promising new treatment for a variety of mental disorders of adolescence. There is currently an adolescent mental health crisis, with a high prevalence of disorders, diagnostic complexity, and many adolescents failing to respond to conventional treatments. While there is strong evidence for the use of ketamine in adults for a variety of treatment-refractory mental illnesses, research in adolescents is in its early stages. Ketamine-assisted psychotherapy (KAP) has been described in adults with promising results and here we present the first published cases of the use of KAP in adolescents. The four cases include adolescents aged 14-19 at the initiation of treatment, each with a variety of comorbid diagnoses including treatment-resistant depression, bipolar disorder, eating disorders, anxiety, panic, and trauma-related symptoms. They each initially received sublingual ketamine, followed by sessions with intramuscular ketamine. Their courses varied, but each had symptomatic and functional improvements, and the treatment was well-tolerated. Subjective patient reports are included. Rapid resolution of symptomatology and suffering often occurs within months as the result of the application of KAP to adolescent psychiatric care but is not inevitable. Family involvement in the treatment process appears to be essential to success. The development of this modality may have a singularly positive impact that will expand the psychiatric toolbox and its healing potency.
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Affiliation(s)
- Philip E. Wolfson
- The Center for Transformational Psychotherapy, San Anselmo, CA, United States
- Ketamine Research Foundation, San Anselmo, CA, United States
- *Correspondence: Philip E. Wolfson
| | - Julane Andries
- The Center for Transformational Psychotherapy, San Anselmo, CA, United States
- Ketamine Research Foundation, San Anselmo, CA, United States
| | - Daniel Ahlers
- The Center for Transformational Psychotherapy, San Anselmo, CA, United States
- Ketamine Research Foundation, San Anselmo, CA, United States
| | - Melissa Whippo
- The Center for Transformational Psychotherapy, San Anselmo, CA, United States
- Ketamine Research Foundation, San Anselmo, CA, United States
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Liu H, Lan X, Wang C, Zhang F, Fu L, Li W, Ye Y, Hu Z, Chao Z, Ning Y, Zhou Y. The efficacy and safety of esketamine in the treatment of major depressive disorder with suicidal ideation: study protocol for a randomized controlled trial. BMC Psychiatry 2022; 22:744. [PMID: 36451150 PMCID: PMC9710171 DOI: 10.1186/s12888-022-04388-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Major depressive disorder (MDD) is a high risk factor for suicide, with up to 20% of MDD patients attempting suicide during their lifetime. Current treatments for MDD are slow onset of action, low efficiency, and the inability to control suicidal behaviors quickly and effectively. Intravenous ketamine has been shown to have a rapid but transient antidepressant effect, but there is still lack evidence on the efficacy and safety of intravenous esketamine in reducing suicidal ideation and depressive symptoms in MDD patients with suicidal ideation. We designed a study to investigate the effect of short-term repeated intravenous infusion of esketamine three times in MDD patients with suicidal ideation. METHODS This study features a randomized, double-blind, placebo-controlled trial (RCT) comparing short-term repeated intravenous infusions of esketamine with placebo as a supplement to conventional antidepressants with an intervention period of 6 days and one infusion every other day, followed by 4 weeks of follow-up. These methods support the examination of the efficacy, safety, tolerability, and mechanism of action of short-term repeated intravenous infusions of esketamine in MDD patients with suicidal ideation. DISCUSSION This is the first RCT to explore the efficacy and safety of short-term repeated infusion of esketamine on suicidal ideation and depressive symptoms in MDD patients with suicidal ideation. If proven effective and tolerated, it will provide evidence for rapid and effective treatment of suicidal ideation and depressive symptoms in MDD individuals with suicidal ideation. TRIAL REGISTRATION Chinese Clinical Trial Register, ChiCTR2000041232 . Registered 22 December 2020.
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Affiliation(s)
- Haiyan Liu
- Guangdong Engineering Technology Research Center for Translational Medicine of Metal Disorders, Guangzhou, China ,grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xiaofeng Lan
- Guangdong Engineering Technology Research Center for Translational Medicine of Metal Disorders, Guangzhou, China ,grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Chengyu Wang
- Guangdong Engineering Technology Research Center for Translational Medicine of Metal Disorders, Guangzhou, China ,grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Fan Zhang
- grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China ,grid.284723.80000 0000 8877 7471The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Ling Fu
- grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China ,grid.284723.80000 0000 8877 7471The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Weicheng Li
- Guangdong Engineering Technology Research Center for Translational Medicine of Metal Disorders, Guangzhou, China ,grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China ,grid.284723.80000 0000 8877 7471The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yanxiang Ye
- Guangdong Engineering Technology Research Center for Translational Medicine of Metal Disorders, Guangzhou, China ,grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Zhibo Hu
- Guangdong Engineering Technology Research Center for Translational Medicine of Metal Disorders, Guangzhou, China ,grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Ziyuan Chao
- grid.410737.60000 0000 8653 1072The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Yuping Ning
- Guangdong Engineering Technology Research Center for Translational Medicine of Metal Disorders, Guangzhou, China. .,The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China. .,The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.
| | - Yanling Zhou
- Guangdong Engineering Technology Research Center for Translational Medicine of Metal Disorders, Guangzhou, China. .,The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
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Mathai DS, Mora V, Garcia-Romeu A. Toward Synergies of Ketamine and Psychotherapy. Front Psychol 2022; 13:868103. [PMID: 35401323 PMCID: PMC8992793 DOI: 10.3389/fpsyg.2022.868103] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/25/2022] [Indexed: 12/13/2022] Open
Abstract
Ketamine is a dissociative drug that has been used medically since the 1970s primarily as an anesthetic agent but also for various psychiatric applications. Anecdotal reports and clinical research suggest substantial potential for ketamine as a treatment in conjunction with psychological interventions. Here, we review historical and modern approaches to the use of ketamine with psychotherapy, discuss the clinical relevance of ketamine’s acute psychoactive effects, propose a unique model for using esketamine (one isomeric form of ketamine) with Acceptance and Commitment Therapy (ACT), and suggest considerations for moving medication-assisted psychotherapy forward as a field.
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Affiliation(s)
- David S Mathai
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Victoria Mora
- School of Health Professions, Baylor College of Medicine, Houston, TX, United States
| | - Albert Garcia-Romeu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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