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Kheirkhah M, Nugent AC, Livinski AA, Neely L, Johnson SC, Henter ID, Varnosfaderani SD, Price RB, Hejazi N, Yavi M, Jamalabadi H, Javaheripour N, Walter M, Zarate CA. Exploring the impact of music on response to ketamine/esketamine: A scoping review. Neurosci Biobehav Rev 2024; 162:105693. [PMID: 38697379 DOI: 10.1016/j.neubiorev.2024.105693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/05/2024]
Abstract
Music and ketamine are both known to affect therapeutic outcomes, but few studies have investigated their co-administration. This scoping review describes the existing literature on the joint use of music and ketamine-or esketamine (the S(+) enantiomer of ketamine)-in humans. The review considers that extant studies have explored the intersection of ketamine/esketamine and music in healthy volunteers and in patients of various age groups, at different dosages, through different treatment processes, and have varied the sequence of playing music relative to ketamine/esketamine administration. Studies investigating the use of music during ketamine anesthesia are also included in the review because anesthesia and sedation were the early drivers of ketamine use. Studies pertaining to recreational ketamine use were omitted. The review was limited to articles published in the English language but not restricted by publication year. To the best of our knowledge, this scoping review is the first comprehensive exploration of the interplay between music and ketamine/esketamine and offers valuable insights to researchers interested in designing future studies.
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Affiliation(s)
- Mina Kheirkhah
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA; Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany.
| | - Allison C Nugent
- Magnetoencephalography Core, National Institute of Mental Health, Bethesda, MD, USA
| | - Alicia A Livinski
- NIH Library, Office of Research Services, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | - Lucinda Neely
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Sara C Johnson
- Department of Psychological Sciences, University of Connecticut, USA
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | | | - Rebecca B Price
- Departments of Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nadia Hejazi
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Mani Yavi
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Hamidreza Jamalabadi
- Department of Psychiatry and Psychotherapy, Philipps University of Marburg, Germany
| | - Nooshin Javaheripour
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Martin Walter
- Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany; Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Di Vincenzo M, Martiadis V, Della Rocca B, Arsenio E, D’Arpa A, Volpicelli A, Luciano M, Sampogna G, Fiorillo A. Facts and myths about use of esketamine for treatment-resistant depression: a narrative clinical review. Front Psychiatry 2024; 15:1394787. [PMID: 38812489 PMCID: PMC11133709 DOI: 10.3389/fpsyt.2024.1394787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/22/2024] [Indexed: 05/31/2024] Open
Abstract
Introduction and aims Treatment-resistant depression (TRD) occurs when at least two different antidepressants, taken at the right dosage, for adequate period of time and with continuity, fail to give positive clinical effects. Esketamine, the S-enantiomer of ketamine, was recently approved for TRD treatment from U.S. Food and Drug Administration and European Medicine Agency. Despite proved clinical efficacy, many misconceptions by clinicians and patients accompany this medication. We aimed to review the most common "false myths" regarding TRD and esketemine, counterarguing with evidence-based facts. Methods The keywords "esketamine", "treatment resistance depression", "depression", "myth", "mythology", "pharmacological treatment", and "misunderstanding" were entered in the main databases and combined through Boolean operators. Results Misconceptions regarding the TRD prevalence, clinical features and predictors have been found. With respect of esketamine, criteria to start treatment, dissociative symptoms, potential addiction and aspects of administration and monitoring, were found to be affected by false beliefs by clinicians and patients. Discussion and conclusion TRD represents a challenging condition, requiring precise diagnosis in order to achieve patient's full recovery. Esketamine has been proved as an effective medication to treat TRD, although it requires precautions. Evidence can inform clinical practice, in order to offer this innovative treatment to all patients with TRD.
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Affiliation(s)
- Matteo Di Vincenzo
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Vassilis Martiadis
- Department of Mental Health, Community Mental Health Center DS 25, Azienda Sanitaria Locale Napoli 1 Centro, Naples, Italy
| | - Bianca Della Rocca
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Eleonora Arsenio
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Andrea D’Arpa
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Antonio Volpicelli
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Mario Luciano
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Andrea Fiorillo
- Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
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3
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Hauser J, Sarlon J, Liwinski T, Brühl AB, Lang UE. Listening to music during intranasal (es)ketamine therapy in patients with treatment-resistant depression correlates with better tolerability and reduced anxiety. Front Psychiatry 2024; 15:1327598. [PMID: 38322143 PMCID: PMC10844460 DOI: 10.3389/fpsyt.2024.1327598] [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: 10/25/2023] [Accepted: 01/04/2024] [Indexed: 02/08/2024] Open
Abstract
Background Although the effectiveness of (es)ketamine for therapy-resistant depression (TRD) has been established, potential treatment-limiting factors include side effects like dissociation, anxiety, or elevated blood pressure. Music can reduce stress and negative emotions as anxiety. This study aimed to investigate the impact of listening to music during intranasal (es)ketamine administration on both tolerability and efficacy. Methods Records of 494 sessions (of 37 patients) with intranasal (es)ketamine administration, each containing data of blood pressure measurements, DSS-IV (dissociation symptoms scale-IV), anxiety and euphoria analogue scale, MADRS (Montgomery-Åsberg Depression Rating Scale) and BDI (Beck's Depression Inventory) were evaluated. Results The between-group analysis, comparing participants who listened to music with those who did not, revealed significant differences in the administered dose (p-value: 0.003, mean: 131.5 mg with music vs. 116.7 mg without music), scores on the DSS Item 1 (p-value: 0.005, mean: 3 points vs. 2.4 points), levels of anxiety (p-value: <0.001, mean: 0.4 points vs. 1.4 points), and measurements of maximal systolic blood pressure after administration (p-value: 0.017, mean: 137.9 mmHg vs. 140.3 mmHg). Listening to music had no impact on the MARDS-change score between the sessions. Limitations Key limitations include a non-randomized naturalistic design and the non-standardized selection of music, which was based on individual patient preferences. Conclusion Listening to music during intranasal (es)ketamine therapy appears to be linked to reduced anxiety and lower blood pressure, stable or increased dissociation levels, and improved tolerance for higher doses. These findings could potentially contribute to the optimization of (es)ketamine therapy, both in terms of treatment efficacy and managing side effects.
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Affiliation(s)
- Johannes Hauser
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
| | - Jan Sarlon
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
| | - Timur Liwinski
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
| | - Annette B. Brühl
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
| | - Undine E. Lang
- University of Basel, Basel, Switzerland
- University Psychiatric Clinics (UPK), Basel, Switzerland
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Chevalier L, Bulteau S, Cheval L, Charron J, Sauvaget A, Laurin A. Differed spontaneous dissociative symptoms following the use of esketamine intranasal spray in a patient suffering from treatment-resistant depression: a case report. Int Clin Psychopharmacol 2024:00004850-990000000-00119. [PMID: 38277263 DOI: 10.1097/yic.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Intranasal esketamine is used in France for treatment-resistant depression. Dissociative symptoms are common side effects during treatment sessions. We report a case of delayed spontaneous dissociative symptoms following esketamine administration. A 20-year-old female with treatment-resistant depression received esketamine treatment. Dissociative symptoms occurred during sessions and persisted at a distance, often accompanied by anxiety. Delayed dissociative phenomena disappeared within the fourth week of treatment by esketamine. The literature mainly discusses dissociation during esketamine treatment sessions, with limited data on differed spontaneous episodes. Three hypotheses are discussed concerning the mechanism of occurrence of these dissociative phenomena, including esketamine's direct effect, central nervous system sensitization, and anxiety-induced dissociation. We present the first case of differed spontaneous dissociative effects after intranasal esketamine administration for treatment-resistant depression. Our main hypothesis suggests that esketamine may act as a 'pattern' for dissociative experiences, heightening the patient's ability to discern these phenomena during other instances of dissociation, such as acute anxiety attacks. Further research is needed to validate this hypothesis.
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Affiliation(s)
| | - Samuel Bulteau
- Nantes Université, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE
| | | | | | - Anne Sauvaget
- Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, UR 4334, Nantes, France
| | - Andrew Laurin
- Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, UR 4334, Nantes, France
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5
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Garel N, Drury J, Thibault Lévesque J, Goyette N, Lehmann A, Looper K, Erritzoe D, Dames S, Turecki G, Rej S, Richard-Devantoy S, Greenway KT. The Montreal model: an integrative biomedical-psychedelic approach to ketamine for severe treatment-resistant depression. Front Psychiatry 2023; 14:1268832. [PMID: 37795512 PMCID: PMC10546328 DOI: 10.3389/fpsyt.2023.1268832] [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: 07/28/2023] [Accepted: 08/30/2023] [Indexed: 10/06/2023] Open
Abstract
Background Subanesthetic ketamine has accumulated meta-analytic evidence for rapid antidepressant effects in treatment-resistant depression (TRD), resulting in both excitement and debate. Many unanswered questions surround ketamine's mechanisms of action and its integration into real-world psychiatric care, resulting in diverse utilizations that variously resemble electroconvulsive therapy, conventional antidepressants, or serotonergic psychedelics. There is thus an unmet need for clinical approaches to ketamine that are tailored to its unique therapeutic properties. Methods This article presents the Montreal model, a comprehensive biopsychosocial approach to ketamine for severe TRD refined over 6 years in public healthcare settings. To contextualize its development, we review the evidence for ketamine as a biomedical and as a psychedelic treatment of depression, emphasizing each perspectives' strengths, weaknesses, and distinct methods of utilization. We then describe the key clinical experiences and research findings that shaped the model's various components, which are presented in detail. Results The Montreal model, as implemented in a recent randomized clinical trial, aims to synergistically pair ketamine infusions with conventional and psychedelic biopsychosocial care. Ketamine is broadly conceptualized as a brief intervention that can produce windows of opportunity for enhanced psychiatric care, as well as powerful occasions for psychological growth. The model combines structured psychiatric care and concomitant psychotherapy with six ketamine infusions, administered with psychedelic-inspired nonpharmacological adjuncts including rolling preparative and integrative psychological support. Discussion Our integrative model aims to bridge the biomedical-psychedelic divide to offer a feasible, flexible, and standardized approach to ketamine for TRD. Our learnings from developing and implementing this psychedelic-inspired model for severe, real-world patients in two academic hospitals may offer valuable insights for the ongoing roll-out of a range of psychedelic therapies. Further research is needed to assess the Montreal model's effectiveness and hypothesized psychological mechanisms.
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Affiliation(s)
- Nicolas Garel
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Jessica Drury
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
| | | | - Nathalie Goyette
- McGill Group for Suicide Studies, Douglas Mental Health Research Institute, Montreal, QC, Canada
| | - Alexandre Lehmann
- International Laboratory for Brain, Music and Sound Research, Montreal, QC, Canada
- Department of Otolaryngology, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Karl Looper
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - David Erritzoe
- Division of Psychiatry, Department of Brain Sciences, Centres for Neuropsychopharmacology and Psychedelic Research, Imperial College London, London, United Kingdom
| | - Shannon Dames
- Health Sciences and Human Services, Vancouver Island University, Nanaimo, BC, Canada
| | - Gustavo Turecki
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- McGill Group for Suicide Studies, Douglas Mental Health Research Institute, Montreal, QC, Canada
| | - Soham Rej
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada
- Geri-PARTy Research Group, Jewish General Hospital, Montreal, QC, Canada
| | - Stephane Richard-Devantoy
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- McGill Group for Suicide Studies, Douglas Mental Health Research Institute, Montreal, QC, Canada
| | - Kyle T. Greenway
- Department of Psychiatry, Faculty of Medicine, McGill University, Montréal, QC, Canada
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada
- Division of Psychiatry, Department of Brain Sciences, Centres for Neuropsychopharmacology and Psychedelic Research, Imperial College London, London, United Kingdom
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6
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Shoib S, Kotra M, Javed S, Nguyen VS, Malathesh BC. Esketamine-A quick-acting novel antidepressant without the disadvantages of ketamine. Horm Mol Biol Clin Investig 2022; 43:505-511. [PMID: 35851448 DOI: 10.1515/hmbci-2021-0099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/23/2022] [Indexed: 12/24/2022]
Abstract
Esketamine, which is an S-enantiomer of ketamine, is better than conventional antidepressants and even better than R-ketamine. This article discusses the mechanism of action of Esketamine, how different it is from other antidepressants, its side effect profile, indications for use, various routes of administration and the review of existing literature on Esketamine.
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Affiliation(s)
- Sheikh Shoib
- Department of Psychiatry, Jawahar Lal Nehru Memorial Hospital, Srinagar, Kashmir, India
| | | | - Sana Javed
- Faculty of Medicine, Aleppo University, Aleppo, Syria
| | - Vinh-Son Nguyen
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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7
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Panariello F, Kasper S, Zohar J, Souery D, Montgomery S, Ferentinos P, Rujescu D, Mendlewicz J, De Ronchi D, Serretti A, Fabbri C. Characterisation of medication side effects in patients with mostly resistant depression in a real-world setting. World J Biol Psychiatry 2022; 24:439-448. [PMID: 36217984 DOI: 10.1080/15622975.2022.2134588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES This study aimed to identify factors associated with side effects of psychotropic drugs in a real-world setting enriched with treatment-resistant depression (TRD) patients. METHODS A total of 1410 depressed patients were treated in a naturalistic setting. Side effects were measured with the Udvalg for Kliniske Undersogelser Side Effect Rating Scale (UKU); the total score and UKU subscales were considered. Clinical-demographic variables were tested for association with side effects in univariate and then multivariate analyses. RESULTS Total, psychic and neurological side effects were associated with depressive symptom severity, while autonomic side effects were higher in those with somatic comorbidities and other side effects were lower in patients receiving trazodone. In multivariate analyses, depressive symptom severity was associated with psychic and total side effects, while generalised anxiety disorder (GAD) with neurological side effects and somatic comorbidities remained associated with autonomic side effects. Trazodone was associated with lower side effects and with augmentation treatments. Augmentation therapies showed opposite effects depending on response status, i.e. increased or decreased the risk of side effects in responders and non-responders/resistant patients, respectively. CONCLUSIONS Psychic side effects may be difficult to distinguish from depressive symptoms and factors associated with different types of side effects are heterogeneous and likely interacting.
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Affiliation(s)
- Fabio Panariello
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Siegfried Kasper
- Center for Brain Research, Medical University of Vienna, Vienna, Austria.,Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Joseph Zohar
- Department of Psychiatry, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Souery
- Laboratoire de Psychologie Medicale, Centre Européen de Psychologie Medicale, Universitè Libre de Bruxelles and Psy Pluriel, Brussels, Belgium
| | | | | | - Dan Rujescu
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Julien Mendlewicz
- Department of Psychiatry, Université Libre de Bruxelles, Brussels, Belgium
| | - Diana De Ronchi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Chiara Fabbri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.,Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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8
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Psiuk D, Nowak EM, Dycha N, Łopuszańska U, Kurzepa J, Samardakiewicz M. Esketamine and Psilocybin—The Comparison of Two Mind-Altering Agents in Depression Treatment: Systematic Review. Int J Mol Sci 2022; 23:ijms231911450. [PMID: 36232748 PMCID: PMC9570062 DOI: 10.3390/ijms231911450] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
This publication discusses two compounds belonging to the psychoactive substances group which are studied in the context of depression treatment—psilocybin and esketamine. The former is a naturally occurring psychedelic. The latter was invented in the laboratory exactly 60 years ago. Although the substances were controversial in the past, recent studies indicate the potential of those substances as novel antidepressant agents. The PubMed/MEDLINE database was used to identify articles for systematic review, using the following search terms: (depression) AND (psilocybin) OR (ketamine). From 617 items, only 12 articles were obtained in the final analyses. Three articles were devoted to psilocybin in depression treatment and nine to esketamine. In most studies, esketamine showed a significant reduction in both depressive symptoms and suicidal ideation shortly after intake and after a month of treatment compared to baseline and to standard-of-care antidepressant agents. Psilocybin’s antidepressive effects occurred one day after intake and after 6–7 weeks of treatment and were maintained for up to 6 or 8 months of follow-up. One study indicated that psilocybin’s effects are comparable with and may be superior to escitalopram treatment. Both esketamine and psilocybin demonstrated rapid and long-term effects in reducing depression symptoms and, after overcoming some limitations, may be considered as novel antidepressant agents in future.
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Affiliation(s)
- Dominika Psiuk
- Students Scientific Association at the Chair and Department of Psychology, Medical University of Lublin, 20-059 Lublin, Poland
- Students Scientific Association at the Department of Medical Chemistry, Medical University of Lublin, 20-059 Lublin, Poland
- Correspondence: or
| | - Emilia Magdalena Nowak
- Students Scientific Association at the Chair and Department of Psychology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Natalia Dycha
- Students Scientific Association at the Department of Medical Chemistry, Medical University of Lublin, 20-059 Lublin, Poland
| | - Urszula Łopuszańska
- Chair and Department of Psychology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Jacek Kurzepa
- Department of Medical Chemistry, Medical University of Lublin, 20-059 Lublin, Poland
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9
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Advances in the treatment of depression. Int Clin Psychopharmacol 2022; 37:183-184. [PMID: 35916263 DOI: 10.1097/yic.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Ceban F, Rosenblat JD, Kratiuk K, Lee Y, Rodrigues NB, Gill H, Subramaniapillai M, Nasri F, Lui LMW, Lipsitz O, Kumar A, Lee JG, Chau EH, Cao B, Lin K, Ho RC, Mansur RB, Swainson J, McIntyre RS. Prevention and Management of Common Adverse Effects of Ketamine and Esketamine in Patients with Mood Disorders. CNS Drugs 2021; 35:925-934. [PMID: 34363603 DOI: 10.1007/s40263-021-00846-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 01/22/2023]
Abstract
The emerging roles of ketamine and esketamine as effective rapid-acting antidepressants hold promise for patients suffering from treatment-resistant depression and/or major depressive disorder with suicidality. Practitioner familiarity with common tolerability/safety concerns along with pragmatic prevention and management strategies are needed to reduce patient burden and improve the acceptability and accessibility of these treatments. The most common treatment-emergent adverse events associated with ketamine/esketamine are dissociation, anxiety, nausea, increased blood pressure, and headache. The majority of side effects are mild, transient, dose dependent, and attenuate with subsequent treatments. Patient selection, baseline physical and psychiatric assessments, and an appropriate setting are critical first steps in the prevention and mitigation of adverse events. Patient education and supportive interventions play central roles in the prevention and management of select adverse events. Severe and/or clinically significant adverse effects may necessitate the judicious use of adjunctive medications. Moreover, practitioners must remain vigilant to the potential for abuse liability and long-term adverse events, for which there are insufficient data. This article succinctly reviews common treatment-emergent adverse events of ketamine and esketamine within the context of mood disorders, and provides practical suggestions for prevention and management at point-of-care.
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Affiliation(s)
- Felicia Ceban
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| | | | - Yena Lee
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada
| | - Hartej Gill
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada
| | - Mehala Subramaniapillai
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada
| | - Flora Nasri
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Leanna M W Lui
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada
| | - Orly Lipsitz
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Braxia Health, Mississauga, ON, Canada
| | | | - Jung Goo Lee
- Department of Psychiatry, College of Medicine, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea.,Paik Institute for Clinical Research, Inje University, Busan, Republic of Korea.,Department of Health Science and Technology, Graduate School, Inje University, Busan, Republic of Korea
| | | | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, People's Republic of China
| | - Kangguang Lin
- Department of Affective Disorders, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou Medical University, Guangzhou, People's Republic of China.,Laboratory of Emotion and Cognition, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Roger C Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada. .,Braxia Health, Mississauga, ON, Canada. .,Department of Psychiatry, University of Toronto, Toronto, ON, Canada. .,Department of Pharmacology, University of Toronto, Toronto, ON, Canada.
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Himmelseher S, Kochs EF. Ready for a "breakthrough" with ketamine? A look at recent pharmacological insights! Curr Opin Anaesthesiol 2021; 34:393-401. [PMID: 34052823 DOI: 10.1097/aco.0000000000001017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW To update pharmacological insights on ketamine integrating information from different disciplines for developing steps to "breakthrough" approaches in clinical challenges. RECENT FINDINGS Pharmacokinetic/pharmacodynamic (PK/PD) models have incorporated recirculation, ketamine metabolites, drug-drug interaction, and covariates such as age. Ketamine-induced relief from treatment-resistant depression has been explained by "disinhibition" of gamma-aminobutyric acid-ergic interneurons and synaptogenic mechanisms requiring neurotrophic signals. Neuroimaging/electroencephalographic investigations have shown an increase in gamma spectral power in healthy volunteers and patients with depression, but also opposite changes in functional network connectivity after subanesthetic ketamine. Volunteer data may not be transferable to clinical conditions. Altered states of consciousness induced by subanesthetic ketamine have been described by disruption of resisting-state functional networks and frontoparietal connectivity with preservation of multisensory and sensor-motor networks. This has been interpreted as a "disconnected consciousness". SUMMARY More precise PK/PD models may improve the ketamine use regimen. The findings from research on depression are an important discovery because ketamine's impact on neuronal plasticity and synaptogenesis in human brain disease has directly been documented. Psychic adverse effects with subanesthetic ketamine are related to a "disconnected consciousness". Overall, progress has been made, but the "breakthrough" still has to come.
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Affiliation(s)
- Sabine Himmelseher
- Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
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Abstract
Intravenous ketamine is an effective treatment of bipolar depression. One of its most important side-effects is a transient altered state of consciousness commonly referred to as dissociation. These states can be anxiety-provoking, distressing and even treatment-limiting, warranting research into mitigation strategies. In this article, we present two cases that demonstrate the potential of adjunctive music to diminish the distress associated with ketamine-induced dissociation - though not necessarily its degree - in bipolar 1 disorder. Both patients suffering from severe depression underwent their first ketamine infusion without music and opted for music with subsequent infusions. They reported that music significantly improved the tolerance of their dissociative symptoms, thereby reducing distress and facilitating subsequent treatments. Both patients achieved remission from their highly treatment-resistant depressive episodes following six ketamine infusions. This is the first report of music's benefits on ketamine for bipolar 1 depression, though there is precedence in the scientific literature on 'psychedelics' where the use of music in combination with medication-induced altered states has been studied. The principles regarding music selection that have resulted from this paradigm may be applicable to the use of ketamine in unipolar and bipolar depression. The optimal use of music with ketamine warrants further research.
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Wang SM, Kim NY, Na HR, Lim HK, Woo YS, Pae CU, Bahk WM. Rapid Onset of Intranasal Esketamine in Patients with Treatment Resistant Depression and Major Depression with Suicide Ideation: A Meta-Analysis. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:341-354. [PMID: 33888663 PMCID: PMC8077059 DOI: 10.9758/cpn.2021.19.2.341] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 12/19/2022]
Abstract
Objective We performed a meta-analysis of randomized double-blinded placebo controlled trials (DB-RCTs) to investigate efficacy and safety of intranasal esketamine in treating major depressive disorder (MDD) including treatment resistant depression (TRD) and major depression with suicide ideation (MDSI). Methods Mean change in total scores on Montgomery-Åsberg Depression Rating Scale (MADRS) from baseline to different time-points were our primary outcome measure. Secondary efficacy measures included rate of remission of depression and resolution of suicidality. Results Eight DB-RCTs (seven published and one un-published) covering 1,488 patients with MDD were included. Esketamine more significantly improved MADRS total scores than placebo starting from 2-4 hours after the first administration (standardized mean difference, -0.41 [95% CI, -0.58 to -0.25], p < 0.00001), and this superiority maintained until end of double-blinded period (28 days). Sub-group analysis showed that superior antidepressant effects of esketamine over placebo in TRD and MDSI was observed from 2-4 hours, which was maintained until 28 days. Resolution of suicide in MDSI was also greater for esketamine than for placebo at 2-4 hours (OR of 2.04, 95% CIs, 1.37 to 3.05, p = 0.0005), but two groups did not statistically differ at 24 hours and day 28. Total adverse events (AEs), and other common AEs including dissociation, blood pressure increment, nausea, vertigo, dysgeusia, dizziness, and somnolence were more frequent in esketamine than in placebo group. Conclusion Esketamine showed rapid antidepressant effects in patients with MDD, including TRD and MDSI. The study also suggested that esketamine might be associated with rapid anti-suicidal effects for patients with MDSI.
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Affiliation(s)
- Sheng-Min Wang
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Nak-Young Kim
- Department of Psychiatry, Keyo Hospital, Uiwang, Korea
| | - Hae-Ran Na
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Kook Lim
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
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