1
|
Joseph B, Nunez NA, Kung S, Vande Voort JL, Pazdernik VK, Schak KM, Boehm SM, Carpenter B, Johnson EK, Malyshev G, Smits N, Adewunmi DO, Brown SK, Singh B. Efficacy of Ketamine with and without Lamotrigine in Treatment-Resistant Depression: A Preliminary Report. Pharmaceuticals (Basel) 2023; 16:1164. [PMID: 37631079 PMCID: PMC10459873 DOI: 10.3390/ph16081164] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Intravenous (IV) ketamine and FDA-approved intranasal (IN) esketamine are increasingly used for treatment-resistant depression (TRD). Preliminary studies have suggested a synergistic effect of ketamine and lamotrigine, although the data are inconclusive. Herein, we report the response to serial ketamine/esketamine treatment among patients with TRD with or without lamotrigine therapy. In this historical cohort study, we included adult patients with TRD who received serial IV racemic ketamine (0.5 mg/kg over 40-100 min) or IN esketamine (56/84 mg) treatments. A change in depressive symptoms was assessed using the 16-item Quick Inventory of Depressive Symptomatology self-report (QIDS-SR) scale. There were no significant differences in response or remission rates among the patients on or not on lamotrigine during the ketamine/esketamine treatments. For a percent change in the QIDS-SR from baseline, no interaction was found between the lamotrigine groups and treatment number (p = 0.70), nor the overall effect of the group (p = 0.38). There was a trend towards lower dissociation (based on the CADSS score) among current lamotrigine users, especially in patients who received IV ketamine. A major limitation is the limited number of patients taking lamotrigine (n = 13). This preliminary study provides insufficient evidence that continuing lamotrigine therapy attenuates the antidepressant effect of repeated ketamine/esketamine; however, there seems to be a signal toward attenuating dissociation with lamotrigine in patients receiving serial ketamine treatments. Further observational studies or randomized controlled trials are needed to replicate these findings.
Collapse
Affiliation(s)
- Boney Joseph
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Nicolas A. Nunez
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Simon Kung
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Vanessa K. Pazdernik
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Kathryn M. Schak
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Stacey M. Boehm
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Brooke Carpenter
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Emily K. Johnson
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Grigoriy Malyshev
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Nathan Smits
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Daniel O. Adewunmi
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Sarah K. Brown
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Balwinder Singh
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN 55905, USA
| |
Collapse
|
2
|
Smith-Apeldoorn SY, Veraart JK, Spijker J, Kamphuis J, Schoevers RA. Maintenance ketamine treatment for depression: a systematic review of efficacy, safety, and tolerability. Lancet Psychiatry 2022; 9:907-921. [PMID: 36244360 DOI: 10.1016/s2215-0366(22)00317-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/30/2022]
Abstract
Ketamine has rapid yet often transient antidepressant effects in patients with treatment-resistant depression. Different strategies have been proposed to prolong these effects. Maintenance ketamine treatment appears promising, but little is known about its efficacy, safety, and tolerability in depression. We searched Pubmed, Embase, and the Cochrane Library and identified three randomised controlled trials, eight open-label trials, and 30 case series and reports on maintenance ketamine treatment. We found intravenous, intranasal, oral, and possibly intramuscular and subcutaneous maintenance ketamine treatment to be effective in sustaining antidepressant effect in treatment-resistant depression. Tachyphylaxis, cognitive impairment, addiction, and serious renal and urinary problems seem uncommon. Despite the methodological limitations, we conclude that from a clinical view, maintenance ketamine treatment seems to be of therapeutic potential. We recommend both controlled and naturalistic studies with long-term follow-up and sufficient power to determine the position of maintenance ketamine treatment within routine clinical practice.
Collapse
Affiliation(s)
- Sanne Y Smith-Apeldoorn
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
| | - Jolien Ke Veraart
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands; Department of Mood Disorders, PsyQ Haaglanden, Parnassia Psychiatric Institute, The Hague, Netherlands
| | - Jan Spijker
- Pro Persona Mental Health Care, Depression Expertise Center, Nijmegen, Netherlands
| | - Jeanine Kamphuis
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| |
Collapse
|
3
|
Chan LF, Woon LSC, Mohd Shukor NA, Eu CL, Ismail N, Chin SJ, Nik Jaafar NR, Baharudin A. Case report: Effectiveness of brexpiprazole and esketamine/ketamine combination: A novel therapeutic strategy in five cases of treatment-resistant depression. Front Psychiatry 2022; 13:890099. [PMID: 35966463 PMCID: PMC9373837 DOI: 10.3389/fpsyt.2022.890099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
A significant proportion of patients with treatment-resistant depression do not attain functional recovery despite administration of multiple steps of pharmacotherapeutic strategies. This highlights the elusiveness of meeting unmet needs in existing pharmacotherapies for treatment-resistant depression. There is accumulating evidence that antidepressant agents involving the glutamatergic system such as brexpiprazole and esketamine/ketamine have more rapid onset of action and potentially improved effectiveness as an augmentation therapy in treatment-resistant depression. This case series aimed to report five complex cases of unipolar and bipolar treatment-resistant depression where conventional treatment strategies were inadequate in managing high risk suicidal behavior and achieving functional recovery. We discussed further the possible synergistic mechanisms of the novel combination strategy of brexpiprazole and esketamine/ketamine, clinical and patient factors that influenced treatment response, challenges with this combination strategy and implications for future practice and research.
Collapse
Affiliation(s)
- Lai Fong Chan
- Department of Psychiatry, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Luke Sy-Cherng Woon
- Department of Psychiatry, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Nuur Asyikin Mohd Shukor
- Department of Psychiatry, Hospital Canselor Tuanku Muhriz, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Choon Leng Eu
- Department of Psychiatry, Hospital Canselor Tuanku Muhriz, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Nurazah Ismail
- Psychiatry Unit, Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia, Nilai, Malaysia
| | - Song Jie Chin
- Department of Psychiatry, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Nik Ruzyanei Nik Jaafar
- Department of Psychiatry, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Azlin Baharudin
- Department of Psychiatry, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| |
Collapse
|
4
|
Chee KY, Muhdi N, Ali NH, Amir N, Bernardo C, Chan LF, Ho R, Ittasakul P, Kwansanit P, Mariano MP, Mok YM, Tran DT, Trinh TBH. A Southeast Asian expert consensus on the management of major depressive disorder with suicidal behavior in adults under 65 years of age. BMC Psychiatry 2022; 22:489. [PMID: 35864465 PMCID: PMC9306096 DOI: 10.1186/s12888-022-04140-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/06/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The high prevalence of suicidal behavior among individuals with major depressive disorder (MDD) in Southeast Asia (SEA) underscores the need for optimized management to address depressive symptoms, reduce suicide risk and prevent suicide in these individuals. Given the lack of clear guideline recommendations for assessing and managing these patients, regional consensus-based recommendations which take into account diverse local contexts across SEA may provide useful guidance for clinical practice. METHODS A narrative literature review and pre-meeting survey were conducted prior to the consensus meeting of an SEA expert panel comprising 13 psychiatrists with clinical experience in managing patients with MDD with suicidal behavior. Utilizing the RAND/UCLA Appropriateness Method, the expert panel developed consensus-based recommendations on the assessment and treatment of adult patients with MDD with suicidal behavior under 65 years. RESULTS Screening of adult patients under 65 years with MDD for suicide risk using both a validated assessment tool and clinical interview is recommended. An improved suicide risk stratification - incorporating both severity and temporality, or using a prevention-focused risk formulation - should be considered. For a patient with an MDD episode with low risk of suicide, use of antidepressant monotherapy, and psychotherapy in combination with pharmacological treatment are both recommended approaches. For a patient with an MDD episode with high risk of suicide, or imminent risk of suicide requiring rapid clinical response, or for a patient who had received adequate AD but still reported suicidal behavior, recommended treatment strategies include antidepressant augmentation, combination use of psychotherapy or electroconvulsive therapy with pharmacological treatment, and inpatient care. Suicide-specific psychosocial interventions are important for suicide prevention and should also be part of the management of patients with MDD with suicidal behavior. CONCLUSIONS There are still unmet needs in the assessment of suicide risk and availability of treatment options that can deliver rapid response in patients with MDD with suicidal behavior. These consensus recommendations on the management of adult patients with MDD with suicidal behavior under 65 years may serve as a useful guidance in diverse clinical practices across the SEA region. Clinical judgment based on careful consideration of individual circumstances of each patient remains key to determining the most appropriate treatment option.
Collapse
Affiliation(s)
- Kok Yoon Chee
- NEURON, Department of Psychiatry & Mental Health, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia.
| | - Nalini Muhdi
- Department of Psychiatry, Dr Soetomo General Hospital; Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Nor Hayati Ali
- Department of Psychiatry & Mental Health, Selayang Hospital, Selayang, Selangor, Malaysia
| | - Nurmiati Amir
- Department of Psychiatry, Ciptomangunkusumo Hospital; Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Carmina Bernardo
- Mood and Anxiety Resource and Referral Center, Professional Services, Department of Neuroscience, Makati Medical Center, Makati City, Philippines
| | - Lai Fong Chan
- Department of Psychiatry, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Roger Ho
- Department of Psychological Medicine, National University Hospital, Singapore, Singapore
| | - Pichai Ittasakul
- Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Melissa Paulita Mariano
- Department of Psychiatry, University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines
| | - Yee Ming Mok
- Institute of Mental Health, Singapore, Singapore
| | - Duy Tam Tran
- Ho Chi Minh Psychiatric Hospital, Ho Chi Minh, Vietnam
| | | |
Collapse
|
5
|
Alnefeesi Y, Chen-Li D, Krane E, Jawad MY, Rodrigues NB, Ceban F, Di Vincenzo JD, Meshkat S, Ho RCM, Gill H, Teopiz KM, Cao B, Lee Y, McIntyre RS, Rosenblat JD. Real-world effectiveness of ketamine in treatment-resistant depression: A systematic review & meta-analysis. J Psychiatr Res 2022; 151:693-709. [PMID: 35688035 DOI: 10.1016/j.jpsychires.2022.04.037] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/10/2022] [Accepted: 04/26/2022] [Indexed: 12/29/2022]
Abstract
Ketamine is a promising therapeutic option in treatment-resistant depression (TRD). The acute efficacy of ketamine in TRD has been demonstrated in replicated randomised-controlled trials (RCTs), but the generalizability of RCT data to real-world practice is limited. To this end, we conducted a systematic review (Search date: 25/12/2021; 1482 records identified) and meta-analysis of studies evaluating the real-world clinical effectiveness of ketamine in TRD patients. Four overlapping syntheses (Total n = 2665 patients; k = 79 studies) and 32 meta-regressions (Total n = 2050; k = 37) were conducted. All results suggest that the mean antidepressant effect is substantial (mean ± 95% CI, % responded = 45 ± 10%; p< 0.0001, % remitted = 30 ± 5.9%; p< 0.0001, Hedges g of symptomatological improvement = 1.44 ± 0.609; p < 0.0001), but the effect varies considerably among patients. The more treatment-resistant cases were found to remit less often (p < 0.01), but no such effect on response was evident (p > 0.05). Meta-regressions also confirmed that the therapeutic effect does not significantly decline with repeated treatments (p > 0.05). These results demonstrate that even the most treatment-resistant patients may benefit from ketamine, and that mid-to-long term treatment is effective in many patients.
Collapse
Affiliation(s)
- Yazen Alnefeesi
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - David Chen-Li
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Ella Krane
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | | | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Felicia Ceban
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Shakila Meshkat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger C M Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
| | - Hartej Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Kayla M Teopiz
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Bing Cao
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, 400715, PR China
| | - Yena Lee
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Pharmacology, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
6
|
Ketamine and Lamotrigine Combination in Psychopharmacology: Systematic Review. Cells 2022; 11:cells11040645. [PMID: 35203296 PMCID: PMC8869907 DOI: 10.3390/cells11040645] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 01/05/2023] Open
Abstract
Background and Objectives: Ketamine is a rapid-acting antidepressant with proven efficacy as an add-on agent in unipolar and bipolar treatment-resistant depression. Although many studies have been published, there is still not enough data on the effect of ketamine in combination with other medications. Particularly interesting is the combination of ketamine and lamotrigine, and its potential role in bipolar depression. The aim of this review was to identify animal and human studies in which ketamine and lamotrigine were used together in order to find out if there is scientific ground for combining ketamine and lamotrigine in the treatment of mood disorders. Directions for future studies are presented. Materials and Methods: PubMed and Web of Science were searched. Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA 2020 methodology was applied. Results: Seventeen studies were included for review. Animal studies using models of depression suggested a synergistic effect of ketamine and lamotrigine in combination. Studies on healthy humans showed a reduction in ketamine-induced dissociative symptoms with lamotrigine pretreatment. In a study on patients with depression, ketamine and lamotrigine did not have a stronger antidepressant effect than ketamine alone, but in this study only one ketamine infusion was administered. One case series described the antidepressant and anti-suicidal effect of the combination in two bipolar patients. Available clinical studies on patients with mood disorders did not support the hypothesis that lamotrigine reduces ketamine-induced dissociative symptoms. Conclusions: The results of the analyzed studies were not sufficient to answer any of the stated questions; however, they allowed us to delineate future research directions. The identified animal studies suggested a possible synergistic antidepressant effect of ketamine and lamotrigine. The available clinical studies were not conclusive. No controlled studies on large groups of bipolar patients with multiple ketamine infusions combined with lamotrigine treatment have been published so far. There is some evidence for the reduction of ketamine’s side effects by lamotrigine, and there are reports suggesting that lamotrigine can reduce ketamine craving. More studies with follow-up are needed in order to investigate the ketamine–lamotrigine combination in bipolar patients.
Collapse
|
7
|
McIntyre RS, Rosenblat JD, Nemeroff CB, Sanacora G, Murrough JW, Berk M, Brietzke E, Dodd S, Gorwood P, Ho R, Iosifescu DV, Jaramillo CL, Kasper S, Kratiuk K, Lee JG, Lee Y, Lui LM, Mansur RB, Papakostas GI, Subramaniapillai M, Thase M, Vieta E, Young AH, Zarate CA, Stahl S. Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation. Am J Psychiatry 2021; 178:383-399. [PMID: 33726522 PMCID: PMC9635017 DOI: 10.1176/appi.ajp.2020.20081251] [Citation(s) in RCA: 308] [Impact Index Per Article: 102.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Replicated international studies have underscored the human and societal costs associated with major depressive disorder. Despite the proven efficacy of monoamine-based antidepressants in major depression, the majority of treated individuals fail to achieve full syndromal and functional recovery with the index and subsequent pharmacological treatments. Ketamine and esketamine represent pharmacologically novel treatment avenues for adults with treatment-resistant depression. In addition to providing hope to affected persons, these agents represent the first non-monoaminergic agents with proven rapid-onset efficacy in major depressive disorder. Nevertheless, concerns remain about the safety and tolerability of ketamine and esketamine in mood disorders. Moreover, there is uncertainty about the appropriate position of these agents in treatment algorithms, their comparative effectiveness, and the appropriate setting, infrastructure, and personnel required for their competent and safe implementation. In this article, an international group of mood disorder experts provides a synthesis of the literature with respect to the efficacy, safety, and tolerability of ketamine and esketamine in adults with treatment-resistant depression. The authors also provide guidance for the implementation of these agents in clinical practice, with particular attention to practice parameters at point of care. Areas of consensus and future research vistas are discussed.
Collapse
Affiliation(s)
- Roger S. McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto; Department of Psychiatry, University of Toronto, Toronto; Department of Pharmacology, University of Toronto, Toronto; Brain and Cognition Discovery Foundation, Toronto
| | - Joshua D. Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto; Department of Psychiatry, University of Toronto, Toronto; Canadian Rapid Treatment Center of Excellence, Mississauga, Ontario
| | - Charles B. Nemeroff
- Department of Psychiatry and Behavioral Sciences, Austin Dell Medical School, University of Texas, Austin
| | - Gerard Sanacora
- Department of Psychiatry, Yale University School of Medicine, New Haven, Conn
| | - James W. Murrough
- Depression and Anxiety Center for Discovery and Treatment, Department of Psychiatry, and Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York
| | - Michael Berk
- Deakin University, Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Orygen, National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Elisa Brietzke
- Department of Psychiatry, Queen’s University School of Medicine, and Centre for Neuroscience Studies, Queen’s University, Kingston, Ontario
| | - Seetal Dodd
- Deakin University, Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Centre for Youth Mental Health and Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Philip Gorwood
- Université de Paris, Institute of Psychiatry and Neuroscience of Paris, INSERM U1266, and GHU Paris Psychiatrie et Neurosciences, CMME, Hôpital Sainte-Anne, Paris
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, and Institute of Health Innovation and Technology, National University of Singapore, Singapore
| | - Dan V. Iosifescu
- Department of Psychiatry, NYU School of Medicine, and Clinical Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, New York
| | | | | | - Kevin Kratiuk
- Canadian Rapid Treatment Center of Excellence, Mississauga, Ontario; Department of Clinical Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jung Goo Lee
- Department of Psychiatry, College of Medicine, Haeundae Paik Hospital, Paik Institute for Clinical Research, and Department of Health Science and Technology, Graduate School, Inje University, Busan, Republic of Korea
| | - Yena Lee
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto; Institute of Medical Science, University of Toronto, Toronto
| | - Leanna M.W. Lui
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto
| | - Rodrigo B. Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto; Department of Psychiatry, University of Toronto, Toronto
| | | | | | - Michael Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz VA Medical Center, Philadelphia
| | - Eduard Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona
| | - Allan H. Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London and South London, and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, Kent
| | - Carlos A. Zarate
- Experimental Therapeutics and Pathophysiology Branch and Section on the Neurobiology and Treatment of Mood Disorders, Division of Intramural Research Program, NIMH, Bethesda, Md
| | - Stephen Stahl
- Department of Psychiatry and Neuroscience, University of California, Riverside, and University of California, San Diego
| |
Collapse
|
8
|
Lascelles K, Marzano L, Brand F, Trueman H, McShane R, Hawton K. Ketamine treatment for individuals with treatment-resistant depression: longitudinal qualitative interview study of patient experiences. BJPsych Open 2020; 7:e9. [PMID: 33283696 PMCID: PMC7791565 DOI: 10.1192/bjo.2020.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Ketamine has recently received considerable attention regarding its antidepressant and anti-suicidal effects. Trials have generally focused on short-term effects of single intravenous infusions. Research on patient experiences is lacking. AIMS To investigate the experiences over time of individuals receiving ketamine treatment in a routine clinic, including impacts on mood and suicidality. METHOD Twelve fee-paying patients with treatment-resistant depression (6 females, 6 males, age 21-70 years; 11 reporting suicidality and 6 reporting self-harm) who were assessed as eligible for ketamine treatment participated in up to three semi-structured interviews: before treatment started, a few weeks into treatment and ≥2 months later. Data were analysed thematically. RESULTS Most participants hoped that ketamine would provide respite from their depression. Nearly all experienced improvement in mood following initial treatments, ranging from negligible to dramatic, and eight reported a reduction in suicidality. Improvements were transitory for most participants, although two experienced sustained consistent benefit and two had sustained but limited improvement. Some participants described hopelessness when treatment stopped working, paralleled by increased suicidal ideation for three participants. The transient nature and cost of treatment were problematic. Eleven participants experienced side-effects, which were significant for two participants. Suggestions for improving treatment included closer monitoring and adjunctive psychological therapy. CONCLUSIONS Ketamine treatment was generally experienced as effective in improving mood and reducing suicidal ideation in the short term, but the lack of longer-term benefit was challenging for participants, as was treatment cost. Informed consent procedures should refer to the possibilities of relapse and associated increased hopelessness and suicidality.
Collapse
Affiliation(s)
- Karen Lascelles
- Oxford Health NHS Foundation Trust; and Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK
| | - Lisa Marzano
- Faculty of Science and Technology, Middlesex University, UK
| | - Fiona Brand
- Oxford Health NHS Foundation Trust; and Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK
| | | | - Rupert McShane
- Department of Psychiatry, University of Oxford; and Oxford Health NHS Foundation Trust, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford; and Oxford Health NHS Foundation Trust, UK
| |
Collapse
|
9
|
Bobo WV, Riva-Posse P, Goes FS, Parikh SV. Next-Step Treatment Considerations for Patients With Treatment-Resistant Depression That Responds to Low-Dose Intravenous Ketamine. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2020; 18:181-192. [PMID: 33162856 DOI: 10.1176/appi.focus.20190048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Numerous short-term randomized trials support the acute-phase efficacy of low-dose intravenous (IV) ketamine for patients with treatment-resistant unipolar or bipolar depression. Ketamine's antidepressive effects generally have limited duration, highlighting the need for maintenance treatment after an acute-phase response. It is increasingly likely that psychiatrists will be called upon to manage the care of patients with treatment-resistant unipolar or bipolar depression who have responded acutely to ketamine and to recommend or initiate next-step treatments. However, there is a paucity of controlled evidence to guide best practices for managing treatment of patients with treatment-resistant unipolar or bipolar depression who have had a positive initial response to ketamine. This article reviews the available evidence supporting specific strategies for extending and maintaining acute antidepressive responses to low-dose IV ketamine in patients with treatment-resistant unipolar or bipolar depression and provides some preliminary considerations for clinical practice.
Collapse
Affiliation(s)
- William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida (Bobo); Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta (Riva-Posse); Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore (Goes); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh)
| | - Patricio Riva-Posse
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida (Bobo); Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta (Riva-Posse); Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore (Goes); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh)
| | - Fernando S Goes
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida (Bobo); Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta (Riva-Posse); Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore (Goes); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh)
| | - Sagar V Parikh
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida (Bobo); Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta (Riva-Posse); Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore (Goes); Department of Psychiatry, University of Michigan, Ann Arbor (Parikh)
| |
Collapse
|
10
|
Polis AJ, Fitzgerald PJ, Hale PJ, Watson BO. Rodent ketamine depression-related research: Finding patterns in a literature of variability. Behav Brain Res 2019; 376:112153. [PMID: 31419519 PMCID: PMC6783386 DOI: 10.1016/j.bbr.2019.112153] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/11/2019] [Accepted: 08/13/2019] [Indexed: 12/23/2022]
Abstract
Discovering that the anesthetic drug ketamine has rapidly acting antidepressant effects in many individuals with major depression is one of the most important findings in clinical psychopharmacology in recent decades. The initial report of these effects in human subjects was based on a foundation of rodent preclinical studies carried out in the 1990s, and subsequent investigation has included both further studies in individuals with depression, as well as reverse translational experiments in animal models, especially rodents. While there is general agreement in the rodent literature that ketamine has rapidly-acting, and generally sustained, antidepressant-like properties, there are also points of contention across studies, including the precise mechanism of action of this drug. In this review, we briefly summarize prominent yet variable findings regarding the mechanism of action. We also discuss a combination of similarities and variances in the rodent literature in the antidepressant-like effects of ketamine as a function of dose, species and strain, test, stressor, and presumably sex of the experimenter. We then present previously unpublished mouse strain comparison data suggesting that subanesthetic ketamine does not have robust antidepressant-like properties in unstressed animals, and may actually promote depression-like behavior, in contrast to widely reported findings. We conclude that the data best support the notion of ketamine action principally via NMDA receptor antagonism, transiently boosting glutamatergic (and possibly other) signaling in diverse brain circuits. We also suggest that future studies should address in greater detail the extent to which antidepressant-like properties of this drug are stress-sensitive, in an effort to better model major depression present in humans.
Collapse
Affiliation(s)
- Andrew J Polis
- University of Michigan, Department of Psychiatry, Ann Arbor, MI 48109-5720, United States of America
| | - Paul J Fitzgerald
- University of Michigan, Department of Psychiatry, Ann Arbor, MI 48109-5720, United States of America
| | - Pho J Hale
- University of Michigan, Department of Psychiatry, Ann Arbor, MI 48109-5720, United States of America
| | - Brendon O Watson
- University of Michigan, Department of Psychiatry, Ann Arbor, MI 48109-5720, United States of America.
| |
Collapse
|
11
|
Rajagukguk S, Lee T. Intravenous Ketamine as an Effective and Safe Treatment in a Suicidal Patient With Cancer Who Was Nil Per Os. PSYCHOSOMATICS 2019; 61:371-374. [PMID: 31739996 DOI: 10.1016/j.psym.2019.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 09/14/2019] [Accepted: 09/23/2019] [Indexed: 11/16/2022]
Affiliation(s)
| | - Timothy Lee
- Loma Linda University Medical Center, Department of Psychiatry, Loma Linda, CA.
| |
Collapse
|