Ketamine, Transcranial Magnetic Stimulation, and Depression Specific Yoga and Mindfulness Based Cognitive Therapy in Management of Treatment Resistant Depression: Review and Some Data on Efficacy

Examining the impact of comorbid posttraumatic stress disorder on ketamine's real-world effectiveness in treatment-resistant depression

Depression with comorbid posttraumatic stress disorder (PTSD) is associated with more severe symptoms and a reduced response to traditional treatments. Although ketamine shows promise as a rapid-acting antidepressant for treatment-resistant depression (TRD), its effectiveness in patients with comorbid PTSD remains underexplored. Therefore, we conducted a retrospective analysis of 134 patients from the Canadian Rapid Treatment Center of Excellence to compare the effectiveness of four ketamine infusions (0.5-0.75 mg/kg) in reducing symptoms of depression and PTSD in TRD patients with and without comorbid PTSD. A repeated-measures linear mixed model was used to evaluate the impact of comorbid PTSD on ketamine's antidepressant effectiveness, measured by the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16). Paired samples t-tests were used to assess changes in PTSD symptoms, measured by the PTSD Checklist for DSM-5 (PCL-5). We found a significant main effect of time on QIDS-SR16 scores, F(4, 209.32) = 36.67, p < 0.001, but no significant group-by-time interaction (p = 0.895), suggesting that comorbid PTSD did not impact the antidepressant effectiveness of ketamine. Significant improvements in PTSD symptoms were observed in overall PCL-5 scores, t(66) = 6.66, p < 0.001, and across all PCL-5 symptom clusters with moderate to large effect sizes. In a real-world sample of TRD patients, ketamine was effective in reducing symptoms of depression and PTSD, regardless of PTSD comorbidity. These findings highlight ketamine's potential as a novel intervention for a patient population that is frequently non-responders to conventional treatments. Future randomized controlled trials should explore mediating factors of improvement and long-term effects.

Cortical paired associative stimulation shows impaired plasticity of inhibition networks as a function of chronic alcohol use

BACKGROUND

Response inhibition - or the ability to withhold a suboptimal response - relies on the efficacy of fronto-striatal networks, and is impaired in neuropsychiatric disorders including addiction. Cortical paired associative stimulation (cPAS) is a form of transcranial magnetic stimulation (TMS) which can strengthen neuronal connections via spike-timing-dependent plasticity mechanisms. Here, we used cPAS targeting the fronto-striatal inhibitory network to modulate performance on a response inhibition measure in chronic alcohol use.

METHODS

Fifty-five participants (20 patients with a formal alcohol use disorder (AUD) diagnosis (26-74 years, 6[30%] females) and 20 matched healthy controls (HCs) (27-73 years, 6[30%] females) within a larger sample of 35 HCs (23-84 years, 11[31.4%] females) underwent two randomized sessions of cPAS 1-week apart: right inferior frontal cortex stimulation preceding right presupplementary motor area stimulation by either 4 ms (excitation condition) or 100 ms (control condition), and were subsequently administered the Stop Signal Task (SST) in both sessions.

RESULTS

HCs showed decreased stop signal reaction time in the excitation condition (t(19) = -3.01, p = 0.007, [CIs]:-35.6 to -6.42); this facilitatory effect was not observed for AUD (F(1,31) = 9.57, p = 0.004, CIs: -68.64 to -14.11). Individually, rates of SST improvement were substantially higher for healthy (72%) relative to AUD (13.6%) groups (OR: 2.33, p = 0.006, CIs:-3.34 to -0.55).

CONCLUSION

In line with previous findings, cPAS improved response inhibition in healthy adults by strengthening the fronto-striatal network through putative long-term potentiation-like plasticity mechanisms. Furthermore, we identified a possible marker of impaired cortical excitability, and, thus, diminished capacity for cPAS-induced neuroplasticity in AUD with direct implications to a disorder-relevant cognitive process.

Effectiveness of yoga for major depressive disorder: A systematic review and meta-analysis

Objective

Major depressive disorder (MDD) has a relapse rate that cannot be ignored and places a tremendous burden on the patient in the prevention and treatment process. Yoga, a combination of physical and mental exercises, is effective and acceptable for the adjunctive treatment of MDD. This study aimed to explore further the evidence of yoga's efficacy for patients with MDD.

Methods

PubMed, Embase, Cochrane library, PsycINFO, SinoMed, CNKI, Wanfang, and VIP databases from their inception to 13 October 2022 were searched by a pre-defined search strategy. RCTs of patients with MDD who met diagnostic criteria for yoga treatment were included. RoB2.0 was used to evaluate the quality of the literature. Improvement in depressive symptoms was assessed by the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAMD), or other scales were used as primary outcome indicators, and improvement in anxiety was assessed by the Hamilton Anxiety Scale (HAMA) and State-Trait Anxiety Inventory (STAI) scale as secondary outcome indicators. RR and Cohen's d at 95% CI were used as effect size estimates, and Q and I2 were used to evaluate the size of heterogeneity, with a p-value less than 0.05 indicating statistical significance.

Results

Thirty-four RCT studies, including 1,269 patients in the treatment group and 1,072 patients in the control group, 48.4% of whom were women, were included in the study. Compared to the control group, the BDI-II results yielded a moderate effect of yoga on the improvement of depressive symptoms (Cohen's d = -0.60; 95% CI: -1.00 to -0.21; p < 0.01), the HAMD results yielded a moderate improvement of yoga on the severity of depressive symptoms (Cohen's d = -0.64; 95% CI: -0.98 to -0.30; p < 0.01), and the STAI results can be concluded that yoga had a negligible effect on the improvement of the level of anxiety (Cohen's d = -0.26; 95% CI: -0.48 to -0.04; p = 0.02). No adverse events occurred in the yoga group during the treatment.

Conclusion

Yoga can improve depressive symptoms and anxiety in patients with MDD and has a safe and wide patient acceptance.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [PROSPERO, CRD42022373282].

Repetitive Transcranial Magnetic Stimulation for the Treatment of Resistant Depression: A Scoping Review

Treatment-resistant depression (TRD) is associated with significant disability, and due to its high prevalence, it results in a substantive socio-economic burden at a global level. TRD is the inability to accomplish and/or achieve remission after an adequate trial of antidepressant treatments. Studies comparing repetitive transcranial magnetic stimulation (rTMS) with electroconvulsive therapy (ECT) and pharmacotherapy have revealed evidence of the therapeutic efficacy of rTMS in TRD. These findings suggest a crucial role for rTMS in the management of TRD. This article aims to conduct a comprehensive scoping review of the current literature concerning the use of rTMS and its therapeutic efficacy as a treatment modality for TRD. PubMed, PsycINFO, Medline, Embase, and Cinahl were used to identify important articles on rTMS for TRD. The search strategy was limited to English articles within the last five years of data publication. Articles were included if they reported on a completed randomized controlled trial (RCT) of rTMS intervention for TRD. The exclusion criteria involved studies with rTMS for the treatment of conditions other than TRD, and study and experimental protocols of rTMS on TRD. In total, 17 studies were eligible for inclusion in this review. The search strategy spanned studies published in the last five years, to the date of the data search (14 February 2022). The regional breakdown of the extracted studies was North American (n = 9), European (n = 5), Asian (n = 2) and Australian (n = 1). The applied frequencies of rTMS ranged from 5 Hz to 50 Hz, with stimulation intensities ranging from 80% MT to 120% MT. Overall, 16 out of the 17 studies suggested that rTMS treatment was effective, safe and tolerated in TRD. For patients with TRD, rTMS appears to provide significant benefits through the reduction of depressive symptoms, and while there is progressive evidence in support of the same, more research is needed in order to define standardized protocols of rTMS application in terms of localization, frequency, intensity, and pulse parameters.

Strategies to Prolong Ketamine's Efficacy in Adults with Treatment-Resistant Depression

INTRODUCTION

Ketamine treatment is capable of significant and rapid symptom improvement in adults with treatment-resistant depression (TRD). A limitation of ketamine treatment in TRD is the relatively short duration of time to relapse (e.g., median 2-4 weeks). The objective of the systematic review herein is to identify strategies capable of prolonging the acute efficacy of ketamine in adults with TRD.

METHODS

PubMed/MEDLINE databases were searched from inception to December 2020 for clinical studies written in English using the following key terms: ketamine, prolong, and depression. A total of 454 articles were identified from the literature search which included all clinical studies regarding prolonging the antidepressant effects of ketamine. Twenty-two articles were included: ten randomized controlled trials (RCTs), eight prospective open-label trials, one retrospective chart review, and three case reports. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data extraction. The primary outcome was prolonged effect, defined as statistically significant antidepressant effects following acute ketamine treatment.

RESULTS

A total of 454 articles were identified, and 22 articles were included. Different treatment modalites including pharmacological interventions, manualized-based psychotherapies, electroconvulsive therapy, transcranial magnetic stimulation, and intravenous monotherapy were examined to determine their impact on the prolongation of antidepressant effects following acute ketamine treatment. No treatment modality, other than repeat-dose IV ketamine, has demonstrated ability to significantly prolong the acute efficacy of IV ketamine in TRD.

CONCLUSION

Hitherto, available open-label data and controlled trial data support repeat administration of IV ketamine as an effective strategy to prolong the efficacy of ketamine's antidepressant effects (although not the focus of the study herein, maintenance repeat-dose esketamine treatment is proven effective in esketamine responders). There is a need to identify multimodality strategies that are safe and capable of prolonging the efficacy of ketamine in adults with TRD.

An Integrative Approach to Ketamine Therapy May Enhance Multiple Dimensions of Efficacy: Improving Therapeutic Outcomes With Treatment Resistant Depression

Research over the last two decades has established ketamine as a safe, effective, fast-acting, and sustained antidepressant that significantly reduces adverse symptoms associated with depression, even in patients who are treatment resistant. Much of this research has evolved within the framework of several independent branches of scientific inquiry: in addition to the study of ketamine is a non-selective NMDAR antagonist with rapid antidepressant effects, it has also been found effective as a psychoplastogen that stimulates synaptogenesis and increases neuroplasticity, as a powerful anti-inflammatory that may improve inflammation-related depressive symptoms, as a substance that induces beneficial high entropy brain states, and as a subjectively impactful psychedelic agent. Each branch of inquiry has generated independent evidence of ketamine's efficacy but has advanced without substantive coordination or communication with other lines of inquiry. Integrative research that considers these branches of research together may lead toward a better understanding of ketamine's effects and improved treatment protocols and clinical outcomes. Such an overview can inform more comprehensive patient care through: (a) informed patient psychoeducation that encompasses all of ketamine's mechanisms of action; (b) calibration of optimal dosage to ensure induction and maintenance of high entropy brain states during each ketamine session utilizing EEG measurement; (c) Improved management of emergence side effects through proper care for set and setting; (d) inclusion of pre-selected appropriate music to enhance the emotional experience; (e) increased monitoring of ketamine effects on cortical activity, inter-hemispheric imbalance, and inflammation-related levels of cytokines to further improvements in ketamine protocols; and (f) appropriate timing of any adjunctive psychotherapy sessions to coincide with peak neurogenesis at 24-48 h post ketamine treatment.

Combining Ketamine, Brain Stimulation (rTMS) and Mindfulness Therapy (TIMBER) for Opioid Addiction

Opioid addiction in the United States currently presents a national crisis despite availability of different treatments. Prior findings suggest that both repetitive transcranial magnetic stimulation (rTMS) and subanesthetic dose of ketamine are efficacious in patients with opioid use disorders (OUD) when administered in isolation. However, their therapeutic value may be undermined by varying clinical responses that tend to dissipate with treatment cessation. There has been no study to date that has used a combination of both for OUD, and there are still many unanswered questions with respect to both. TIMBER (Trauma Interventions using Mindfulness Based Extinction and Reconsolidation of memories) therapy attempts to alter the expression of emotionally charged memories such as traumatic memories, and has been successfully tried in chronic post-traumatic stress disorder (PTSD) and in combination with memory-altering pharmacotherapy like ketamine infusion. By a combination of extinction and reconsolidation of memory approaches, TIMBER works to not over-flood and/or retraumatize as is seen in other treatment approaches. TIMBER involves a balanced combination of both the memory extinction and memory reconsolidation approaches (rather than extinction-only approaches) which explains its superior efficacy in PTSD and benefit in substance use disorders.

Efficacy of repetitive transcranial magnetic stimulation in treatment-resistant depression: the evidence thus far

Depression is a common mental disorder, which attributes to significant morbidity, disability and burden of care. A significant number of patients with depression still remain symptomatic after adequate trials of antidepressant treatment as well as psychotherapy, which is often referred to as treatment-resistant depression. Neuromodulation techniques-like electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation (TMS) and transcranial direct current stimulation, may be useful augmenting techniques in depression, mostly recommended for treatment-resistant cases. Robust evidence exists regarding the efficacy of electroconvulsive therapy in the management of treatment-resistant depression; however, other techniques are understudied. TMS has been increasingly studied in various psychiatric disorders including depression. It has been approved by the US Food and Drug Administration for use in major depressive disorder. Over the past two decades, TMS has been studied in diverse groups of the population with depression using several research designs. This article gives an overview of the efficacy of repetitive TMS in treatment-resistant depression with the recent evidence.

Ketamine for the treatment of major depressive disorder and bipolar depression: A review of the literature

Introduction

Over the past decade, ketamine has been studied for major depressive disorder and bipolar depression. Ketamine is believed to exert its antidepressant properties through N-methyl-D-aspartate receptor antagonism.

Methods

Study authors completed a literature review of seven randomized controlled trials of ketamine usage in major depressive disorder and bipolar depression.

Results

Ketamine demonstrated a statistically significant improvement over placebo or midazolam in major depressive disorder. Ketamine also exhibited a statistically significant improvement over placebo in bipolar depression.

Discussion

Ketamine has shown promise in quickly reducing symptoms in patients with treatment resistant depression and bipolar depression. Using ketamine may be helpful for patients that have exhausted other therapeutic options.

Yoga Therapy in Children with Cystic Fibrosis Decreases Immediate Anxiety and Joint Pain

This study was designed to determine whether yoga might alleviate symptoms of pain, sleep disturbance, anxiety, and depression in children with cystic fibrosis (CF). CF is the most common genetic, life-limiting chronic disease among Caucasian populations. It primarily affects the lungs but also many other secretory organs and consequently leads to significant morbidities. Research has shown that children with CF have significantly increased depression, anxiety, and pain compared to their healthy counterparts. Subjects participated in six one-on-one sessions over a 10-week period with a certified instructor who designed each yoga practice based on a preestablished list of 30 yoga asanas. Questionnaires evaluating pain, sleep disturbance, sustained anxiety, immediate anxiety, and depression were administered. Differences between premeasures and postmeasures were evaluated using a two-sided test. Twenty subjects were assessed (12 females/8 males), median age of 11 (7-20) years. Mean immediate anxiety scores decreased (before session to after session 29 to 23.6, respectively, p < 0.001). Joint pain improved (3.25 to 3.65, p = 0.028). CFQ-R emotion subscale improved from 79.2 to 85 (p = 0.073), and the respiratory subscale improved from 66.7 to 79.2 (p = 0.076). Other results were less notable. We conclude that yoga may reduce immediate anxiety and joint pain in patients with CF.