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Palhano-Fontes F, Cavalcanti-Ribeiro P, da Costa Gonçalves KT, de Almeida VRN, Barbosa DC, de Araújo Ferreira MA, Bolcont R, De Souza LCAM, Santos NC, Lopes EITC, de Medeiros Lima NB, de Brito AJC, Falchi-Carvalho M, Arcoverde E, Araujo D, Galvão-Coelho NL. Repeated subcutaneous esketamine on treatment-resistant depression: An open-label dose titration study. J Affect Disord 2024; 369:155-163. [PMID: 39341294 DOI: 10.1016/j.jad.2024.09.141] [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: 05/14/2024] [Revised: 09/10/2024] [Accepted: 09/21/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Ketamine has gained prominence as one of the most effective therapeutic options in unipolar treatment-resistant depression (TRD). However, most studies related to the antidepressant action of ketamine used intravenous (IV) or intranasal (IN) administration. The subcutaneous (SC) route of administration is a promising alternative, as it results in plasma levels comparable to IV, causes fewer side effects, and is easier and cheaper to administer than both IV and/or IN routes. METHODS In this context, we conducted an open-label clinical trial for investigating the efficacy and safety of 8 weekly sessions of SC esketamine in TRD patients (n = 30). RESULTS At the end of the treatment, a partial response rate of 26.09 %, a response rate of 52.17 % and remission rate of 34.78 % were observed, assessed by Montgomery-Åsberg Depression Rating Scale. Moreover, the self-reported depressive symptoms, as measured by the Beck Depression Inventory II (BDI-II), significantly decreased from the baseline to the final session, and the improvements were sustained throughout the week. Follow-up evaluations (BDI-II) up to the sixth month consistently showed scores lower than the baseline. LIMITATIONS The small sample size and the drop-out during the follow-up phase may limit the generalizability of the findings. Additionally, the absence of a control group necessitates cautious interpretation of causality. CONCLUSIONS This groundbreaking study, which addresses SC esketamine treatment for TRD, reported promising response and remission rates, as well as sustained antidepressant effects. It highlights the need for further research to improve and expand our knowledge of this innovative, more accessible, and cost-effective therapeutic approach.
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Affiliation(s)
- Fernanda Palhano-Fontes
- Brain Institute, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil; Center for Advanced Psychedelic Medicine, Natal, RN, Brazil
| | - Patricia Cavalcanti-Ribeiro
- University Hospital Onofre Lopes, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil; Psychobiology Postgraduate Program, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | - Emerson Arcoverde
- University Hospital Onofre Lopes, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Draulio Araujo
- Brain Institute, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil; Center for Advanced Psychedelic Medicine, Natal, RN, Brazil
| | - Nicole Leite Galvão-Coelho
- Psychobiology Postgraduate Program, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil; Center for Advanced Psychedelic Medicine, Natal, RN, Brazil.
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Feng X, Jia P, Zhang D. Nanocarrier drug delivery system: promising platform for targeted depression therapy. Front Pharmacol 2024; 15:1435133. [PMID: 39119603 PMCID: PMC11306052 DOI: 10.3389/fphar.2024.1435133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 07/11/2024] [Indexed: 08/10/2024] Open
Abstract
Depression is a chronic mental disorder characterized by persistent low mood and loss of interest. Treatments for depression are varied but may not be sufficient cure. Drug-based treatment regimens have drawbacks such as slow onset of action, low bioavailability, and drug side effects. Nanocarrier Drug Delivery Systems (NDDS) has received increasing attention for brain drug delivery since it assists the drug through the blood-brain barrier and improves bioavailability, which may be beneficial for treating depression. Due to the particle size and physicochemical properties of nanocarriers, it presents a promise to improve the stability and solubility of antidepressants, thereby enhancing the drug concentration. Moreover, ligand-modified nanocarriers can be taken as a target direct medicines release system and reduce drug side effects. The purpose of the present review is to provide an up-to-date understanding of the Nanocarrier drug delivery system and relevant antidepressants in different routes of ingestion, to lay a foundation for the treatment of patients with depression.
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Affiliation(s)
- Xiaoying Feng
- College of Medical Technology, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ping Jia
- Department of Neurosurgery Nursing, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Dingding Zhang
- Sichuan Provincial Key Laboratory for Genetic Disease, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Xu Z, Lang Y, Xu X, Deng L, Song H, Yin D. The ED50 and ED95 of esketamine for preventing early postoperative pain in patients undergoing laparoscopic cholecystectomy: a prospective, double-blinded trial. BMC Anesthesiol 2023; 23:385. [PMID: 38001477 PMCID: PMC10675926 DOI: 10.1186/s12871-023-02357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/22/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND This study aims to estimate the safety, efficacy, and median effective dose (ED50) of esketamine for preventing early postoperative pain in patients undergoing laparoscopic cholecystectomy. METHODS 54 patients undergoing laparoscopic cholecystectomy were prospectively randomized into two groups (group C and group E). Different doses of esketamine were intravenously administered before the skin incision in Group E. The patients in group C received the same dose of saline at the same time. General population characteristics were recorded. The median effective dose (ED50) and 95% effective dose (ED95) were calculated using Dixon's up-and-down method. Hemodynamic parameters were monitored, and pain intensity was assessed using a visual analog scale. We also recorded the condition of anesthesia recovery period and postoperative adverse reactions. RESULTS The ED50 of esketamine for preventing early postoperative pain was 0.301 mg/kg (95%CI: 0.265-0.342 mg/kg), and the ED95 was 0.379 mg/kg (95%CI: 0.340-0.618 mg/kg), calculated by probability unit regression. Heart rate (HR) was significantly lower in the esketamine group compared to the control at the skin incision (p < 0.05). The total VAS score at resting was significantly lower in the esketamine group compared to the control group during the awakening period (p < 0.05). There was no significant difference between the two groups regarding the incidence of adverse reactions (p > 0.05). CONCLUSIONS In this study, esketamine can prevent early postoperative pain effectively. The ED50 and ED95 of esketamine for controlling early postoperative pain were 0.301 mg/kg and 0.379 mg/kg, respectively. TRIAL REGISTRATION ChiCTR2200066663, 13/12/2022.
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Affiliation(s)
- Zhongling Xu
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu province, China
| | - Yantao Lang
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu province, China
| | - Xiaolei Xu
- Department of Anesthesiology, Funing People's Hospital of Jiangsu, Yancheng, 224400, Jiangsu province, China
| | - Linjuan Deng
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu province, China
| | - Hengya Song
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu province, China.
| | - Dekun Yin
- Department of Anesthesiology, Funing People's Hospital of Jiangsu, Yancheng, 224400, Jiangsu province, China.
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Luo J, Yin K, Zhao D, Zhang Z, Sun R. Effect of intravenous induction with different doses of Esketamine combined with propofol and sufentanil on intraocular pressure among pediatric strabismus surgery: a randomized clinical trial. BMC Anesthesiol 2023; 23:275. [PMID: 37582704 PMCID: PMC10426143 DOI: 10.1186/s12871-023-02238-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/08/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND It is well-established that maintaining stable intraocular pressure (IOP) within the normal range during ophthalmic surgery is important. Esketamine is a commonly used drug in pediatric general anesthesia due to its good analgesic and sedative effects. However, its application in ophthalmic surgery is limited because it can increase IOP. The effect of esketamine combined with other common anesthetics on IOP has been underinvestigated. This study aimed to investigate the effect of different doses of esketamine combined with propofol and sufentanil on IOP during intravenous induction of general anesthesia for pediatric strabismus surgery. METHODS A total of 181 children with strabismus undergoing unilateral eye surgery under general anesthesia were recruited. Intravenous induction included the use of sufentanil 0.1 µg/kg, propofol 3 mg/kg, and esketamine. Base on the dosage of esketamine, the patients were randomly allocated into three groups: esketamine low (EL) group with 0.25 mg/kg (n = 62), esketamine high (EH) group with 0.5 mg/kg (n = 60), and normal saline (NS) group (n = 59). Hemodynamic parameters, respiratory parameters, and IOP of the non-surgical eye were recorded and compared among the three groups at different time points: before induction (T0), 1 min after induction but before laryngeal mask insertion (T1), immediately after laryngeal mask insertion (T2), and 2 min after laryngeal mask insertion (T3). RESULTS There were no significant differences in age, gender, body mass index (BMI), and respiratory parameters among the three groups at T0. The IOP at T1, T2, and T3 was lower than that at T0 in all three groups. The EH group (12.6 ± 1.6 mmHg) had a significantly higher IOP than the EL group (12.0 ± 1.6 mmHg) and the NS group (11.6 ± 1.7 mmHg) at T1. However, no difference was found between the EL and NS groups at any time point. Systolic blood pressure (SBP) and heart rate (HR) at T1, T2, and T3 were lower than at baseline, and SBP and HR were higher at T2 than at T1. Additionally, the EH group had a significantly higher HR at T1 than the other two groups. There was no significant difference in diastolic blood pressure (DBP) among the three groups at any time point. CONCLUSION Propofol combined with sufentanil significantly decreased IOP during the induction of general anesthesia. Although a dose of 0.5 mg/kg esketamine elevated IOP compared to the low-dose and control groups after induction, the IOP remained lower than baseline. 0.25 mg/kg esketamine combined with propofol and sufentanil had little effect on IOP. Therefore, we advocate that a maximum dose of 0.5 mg/kg esketamine combined with propofol and sufentanil will not elevate IOP compared to baseline in pediatric strabismus surgery. TRIAL REGISTRATION The registration number is ChiCTR2200066586 at Chictr.org.cn. Registry on 09/12/2022.
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Affiliation(s)
- Jun Luo
- Department of Anesthesiology, Tianjin Eye Hospital, 4 Gansu Road, 300020, Tianjin, China
| | - Kuoqi Yin
- Department of Anesthesiology, Tianjin Eye Hospital, 4 Gansu Road, 300020, Tianjin, China
| | - Dinghuan Zhao
- Department of Anesthesiology, Tianjin Eye Hospital, 4 Gansu Road, 300020, Tianjin, China
| | - Zhao Zhang
- Department of Anesthesiology, Tianjin Eye Hospital, 4 Gansu Road, 300020, Tianjin, China
| | - Ruiqiang Sun
- Department of Anesthesiology, Tianjin Eye Hospital, 4 Gansu Road, 300020, Tianjin, China.
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Impact of Repeated Doses of Subcutaneous Esketamine on Acute Dissociative Symptoms in Treatment-Resistant Depression. Pharmaceuticals (Basel) 2022; 16:ph16010031. [PMID: 36678528 PMCID: PMC9861342 DOI: 10.3390/ph16010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Esketamine has been approved by the US Food and Drug Administration (FDA) as an adjunctive treatment for use in conjunction with an oral antidepressant for patients with treatment-resistant depression (TRD), but dissociative symptoms are common adverse effects. METHODS A retrospective analysis of 394 subcutaneous esketamine injections given to 70 patients with TRD that were administered once a week during a six-week trial in conjunction with oral antidepressant therapy. Doses between 0.5 to 1.0 mg/kg were administered according to the patient's response. Dissociative symptoms were assessed using the Clinician-Administered Dissociative States Scale (CADSS) 30 and 60 min after every weekly treatment (day 1, 8, 15, 22, 29 and 36). RESULTS Seventy patients received a total of 394 subcutaneous esketamine injections over six weeks. Over time, the evolution of CADSS scores demonstrated a significant mean difference of CADSS at 60 min post-injection (p = 0.010) throughout the six infusions. The mean CADSS scores at 60 min on day 22, 29 and 36 were similar. There were no differences between mean CADSS scores 30 min after the injections, no clinical correlation between response and dissociative symptoms, no correlation between time and demographic and clinical characteristics and no interactions between time and combined medication. CONCLUSIONS Our results suggest that repeated subcutaneous esketamine doses are safe and well-tolerated regarding their acute dissociative and psychotomimetic symptoms. Symptoms usually peak at 30 min and decrease at 60 min post-injection, returning to their pretreatment levels at 120 min. Dissociative symptoms do not correlate with antidepressant response.
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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: 37] [Impact Index Per Article: 18.5] [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.
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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
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Surjan J, Grossi JD, Del Porto JA, Delfino RS, de Oliveira Cerqueira R, Lucchese AC, Magalhães E, Del Sant LC, Tuena MA, Nakahira C, Fava VAR, Steglich MS, Abdo GL, Barbosa MG, Sarin LM, Lacerda ALT. Efficacy and Safety of Subcutaneous Esketamine in the Treatment of Suicidality in Major Depressive Disorder and Bipolar Depression. Clin Drug Investig 2022; 42:865-873. [PMID: 36044154 DOI: 10.1007/s40261-022-01193-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Affective disorders account for most cases of suicide. The pharmacological arsenal to treat suicidality is limited and available agents take too long to take effect. A large body of evidence shows optimal results of ketamine for treating depression, but the evidence concerning suicidality has not been fully described. We report the first real-world study of severely depressed patients presenting with suicide ideation who were treated with repeated administration of subcutaneous esketamine. METHODS We analyzed data from 70 acutely depressed subjects diagnosed with resistant major depressive disorder or bipolar depression. Subjects were administered subcutaneous esketamine once a week for 6 weeks. The primary efficacy endpoint, the change from baseline to 24-h post-administration 6 in the item 10 Montgomery-Åsberg Depression Rating Scale score, was analyzed using a mixed-effects repeated-measures model. RESULTS There were significant effects for time on item 10 Montgomery-Åsberg Depression Rating Scale scores (p < 0.0001) but not for a time × diagnosis interaction (p = 0.164) from baseline to the end of the study. Efficacy of esketamine did not differ between groups (major depressive disorder vs bipolar depression) at any timepoint. Statistical significance on suicidality scores was observed from 24 h after the first administration (p < 0.001), and a further reduction was observed with repeated administrations. Esketamine was safe and well tolerated. Mean heart rate remained stable during the administrations and the blood pressure increase was self-limited. CONCLUSIONS Repeated subcutaneous esketamine administration had significant anti-suicidality effects in both major depressive disorder and bipolar groups, with a rapid onset of action and a good tolerability profile. Large randomized controlled trials are warranted to confirm these preliminary findings.
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Affiliation(s)
- Juliana Surjan
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | | | - José Alberto Del Porto
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Rodrigo Simonini Delfino
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Raphael de Oliveira Cerqueira
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Ana Cecília Lucchese
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Magalhães
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Lorena Catarina Del Sant
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Aurélio Tuena
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Matheus Souza Steglich
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Guilherme Lozi Abdo
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Matheus Ghossain Barbosa
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Luciana Maria Sarin
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil. .,CNS Unit, BR Trials, Sao Paulo, Brazil. .,LiNC-Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Keith KM, Geller J, Froehlich A, Arfken C, Oxley M, Mischel N. Vital Sign Changes During Intravenous Ketamine Infusions for Depression: An Exploratory Study of Prognostic Indications. J Clin Psychopharmacol 2022; 42:254-259. [PMID: 35476091 DOI: 10.1097/jcp.0000000000001542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND Subanesthetic dosing of intravenous ketamine has shown to be an effective treatment for patients with major depressive disorder. It is unknown whether sympathetic response is related to treatment outcomes. The purpose of this study is to evaluate sympathetic response to ketamine infusions as it relates to treatment outcomes. METHODS/PROCEDURES This retrospective study examines an outpatient population diagnosed with major depressive disorder or bipolar depression treated with ketamine infusions. Patient characteristics, depressive symptoms measured with the Patient Health Questionnaire (PHQ-9), and vital signs were retrieved by chart review. Patients (n = 145) were categorized as responders (50% reduction in PHQ-9 or less than 10 on final PHQ-9) or nonresponders. Changes in vital signs were recorded during each infusion for the initiation series. FINDINGS/RESULTS Ketamine responders (51.7%) showed a significant greater increase in systolic blood pressure response during the first infusion when compared with nonresponders. There was no difference seen in diastolic pressure, heart rate, or rate pressure product. Changes in vital signs for subsequent infusions also did not approach significance. IMPLICATIONS/CONCLUSIONS Physiologic sensitivity to the effects of ketamine may predict treatment responsiveness. Blood pressure and heart rate did not always increase. Further work should examine possible influences on physiologic responses.
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Affiliation(s)
- Katherine M Keith
- From the Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit
| | - Jamarie Geller
- Department of Psychiatry, University of Michigan Health, Ann Arbor
| | | | - Cynthia Arfken
- From the Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit
| | | | - Nicholas Mischel
- From the Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit
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Smith-Apeldoorn SY, Vischjager M, Veraart JK, Kamphuis J, Aan Het Rot M, Schoevers RA. The antidepressant effect and safety of non-intranasal esketamine: A systematic review. J Psychopharmacol 2022; 36:531-544. [PMID: 35546042 PMCID: PMC9112628 DOI: 10.1177/02698811221084055] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The introduction of esketamine into the field of psychiatry comes on the heels of excitement from studies on racemic ketamine. While the intranasal route has been the most studied to date, other modes of administration of esketamine may also be of interest in the management of depression. AIMS To systematically review the literature on non-intranasal esketamine for depression in terms of its antidepressant effect and safety. METHODS We searched PubMed, Embase, the Cochrane Library, and Google Scholar from inception up to February 2021. Search terms included a combination of Medical Subject Headings and text words indicative of esketamine and depression. We selected both controlled and uncontrolled studies examining non-intranasal esketamine for the treatment of depression. RESULTS We identified four randomized controlled trials (RCTs) on intravenous esketamine and 15 open-label studies on intravenous (n = 80), subcutaneous (n = 73), and oral (n = 5) esketamine. We found intravenous, subcutaneous, and possibly oral administration of esketamine to be effective in reducing depressive symptoms in most patients with major depressive disorder, bipolar depression, and (severe) treatment-resistant depression. Clinical response to repeated administration of esketamine persisted over the course of treatment. Esketamine was well tolerated by most patients, but open-label data indicate marked psychotomimetic symptoms in exceptional cases. The overall quality of the controlled studies was considered high, the overall quality of the uncontrolled studies low to moderate. CONCLUSIONS Intravenous, subcutaneous, and possibly oral esketamine may offer an effective and safe addition to the depression treatment armamentarium. However, as most included studies lacked a control group and had small sample sizes, the quality of our results is limited. Different types and formulations of ketamine remain to be compared directly.
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Affiliation(s)
- Sanne Y Smith-Apeldoorn
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maurice Vischjager
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jolien Ke Veraart
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Mood Disorders, PsyQ Haaglanden, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Jeanine Kamphuis
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marije Aan Het Rot
- Department of Psychology, University of Groningen, Groningen, The Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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10
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Lucchese AC, Sarin LM, Magalhães EJM, Del Sant LC, B Puertas C, Tuena MA, Nakahira C, Fava VA, Delfino R, Surjan J, Steiglich MS, Barbosa M, Abdo G, Cohrs FM, Liberatori A, Del Porto JA, Lacerda AL, B Andreoli S. Repeated subcutaneous esketamine for treatment-resistant depression: Impact of the degree of treatment resistance and anxiety comorbidity. J Psychopharmacol 2021; 35:142-149. [PMID: 33427015 DOI: 10.1177/0269881120978398] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND A large number of studies indicate that subanesthetic doses of ketamine induce a fast antidepressant effect. Limited studies have investigated the subcutaneous (SC) route, and it remains unclear for whom this treatment is most suitable. AIMS The aim of this study was to examine the effect on depressive symptoms of repeated subanesthetic doses of SC esketamine in unipolar and bipolar treatment-resistant depression (TRD) and clinical predictors of response. METHODS A retrospective analysis of 70 patients who received six SC esketamine doses weekly as an adjunctive treatment was carried out. Doses started at 0.5 mg/kg and it could be titrated up to 1 mg/kg, according to response. The primary outcome was reduction in depressive symptoms. Statistical analysis to investigate clinical predictors of effectiveness included logistic regression analysis using a dependent variable of a 50% reduction in rating scale scores at the end of treatment. Comparisons between groups were made through analysis of variance and treatment effects. RESULTS At baseline, our sample presented with severe treatment resistance in 65.7%, as assessed by the Maudsley Staging Method (MSM), and 47.1% had anxiety disorder comorbidity. The response rate was 50%. A better outcome was predicted by mild and moderate MSM scores (OR = 3.162, p = 0.041) and anxiety disorder comorbidity (OR = 3.149, p = 0.028). CONCLUSIONS Our results suggest that higher levels of treatment resistance may be associated with a poor response to SC esketamine. Unlike traditional pharmacotherapies, it might benefit those with poor prognosis such as patients with depression and comorbid anxiety. Therefore, future research could investigate whether esketamine should receive a more prominent place in the treatment algorithm for TRD.
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Affiliation(s)
- Ana C Lucchese
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Luciana M Sarin
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Lorena C Del Sant
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Camila B Puertas
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco A Tuena
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Victor Ar Fava
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Delfino
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus S Steiglich
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Barbosa
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Abdo
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Frederico M Cohrs
- Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Aroldo Liberatori
- Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - José A Del Porto
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Lt Lacerda
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, LiNC - Laboratory of Integrative Neuroscience, Federal University of Sao Paulo, Sao Paulo, Brazil
- Center for Interventional Psychiatry, Hospital Sao Marcos, Jaboticabal, Brazil
| | - Sergio B Andreoli
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
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11
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Veraart JKE, Kamphuis J, Schlegel M, Schoevers RA. Oral S-ketamine effective after deep brain stimulation in severe treatment-resistant depression and extensive comorbidities. BMJ Case Rep 2021; 14:14/1/e238135. [PMID: 33495180 PMCID: PMC7839911 DOI: 10.1136/bcr-2020-238135] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
This case report describes successful maintenance treatment with oral S-ketamine in a patient with severe depression, who previously was resistant to electroconvulsive therapy and deep brain stimulation, and who also had comorbid psychotic and obsessive compulsive symptoms.
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Affiliation(s)
- Jolien K E Veraart
- Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands .,PsyQ Haaglanden, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Jeanine Kamphuis
- Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Mathis Schlegel
- Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Research School of Behavioural and Cognitive Neurosciences (BCN), University of Groningen, Groningen, The Netherlands
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12
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Ludwig VM, Sauer C, Young AH, Rucker J, Bauer M, Findeis H, Ritter P. Cardiovascular Effects of Combining Subcutaneous or Intravenous Esketamine and the MAO Inhibitor Tranylcypromine for the Treatment of Depression: A Retrospective Cohort Study. CNS Drugs 2021; 35:881-892. [PMID: 34283390 PMCID: PMC8354966 DOI: 10.1007/s40263-021-00837-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND (Es)ketamine and monoamine oxidase inhibitors (MAOIs), e.g., tranylcypromine, are therapeutic options for treatment-resistant major depression. Simultaneous administration is currently not recommended because of concern about hypertensive crises. OBJECTIVE Our objective was to evaluate whether changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) during esketamine administration differed between patients who concomitantly received tranylcypromine and those who did not. METHODS This was a retrospective cohort study utilizing cardiovascular monitoring data from inpatients treated for severe depression in unipolar, bipolar, and schizoaffective disorder. Primary outcomes were change in mean BP and HR during the first hour after intravenous or subcutaneous esketamine administration compared with baseline, controlled for confounders. Secondary analyses quantify differences in absolute BP during esketamine treatment and comparisons of BP peaks, temporal effects, and intraindividual comparisons before and after tranylcypromine initiation. RESULTS Our analysis included 509 esketamine administrations in 43 patients, 14 of whom concomitantly received tranylcypromine. Controlling for creatinine and age, mean ± standard deviation (SD) BP changes were significantly increased by concomitant tranylcypromine treatment (ΔSBP: F[1,503] = 86.73, p < 0.001; ΔDBP: F[1,503] = 55.71, p < 0.001), but HR remained unaffected. Mean SBP change during esketamine administration was 2.96 ± 18.11 mmHg in patients receiving tranylcypromine (TCP+) and -8.84 ± 11.31 mmHg in those who did not (TCP-). Changes in DBP were -2.81 ± 11.20 mmHg for TCP+ and -10.77 ± 9.13 mmHg for TCP-. Moreover, we found a significant dose-response relationship between tranylcypromine dose and BP (SBP: B = 0.35, standard error [SE] = 0.12, 95% confidence interval [CI] 0.12-0.60, p = 0.004; adjusted R2 = 0.11, p = 0.008; DBP: B = 0.21, SE = 0.08, 95% CI 0.06-0.36, p = 0.007; adjusted R2 = 0.08; p = 0.023). CONCLUSIONS Although statistically significant changes in BP were identified in patients receiving tranylcypromine and esketamine, these changes were clinically insignificant. Thus, combining esketamine and this MAOI appears to be safe at standard doses. The dose-response relationship calls for caution with higher doses of tranylcypromine.
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Affiliation(s)
- Vera M. Ludwig
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Cathrin Sauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Allan H. Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK ,South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent UK
| | - James Rucker
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hannelore Findeis
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Philipp Ritter
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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13
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Magalhães EJM, Sarin LM, Del Sant LC, Lucchese AC, Nakahira C, Tuena MA, Puertas CB, Rodovalho Fava VA, Delfino RS, Surjan J, Steglich MS, Barbosa MG, Abdo G, Del Porto JA, Nemeroff CB, Cogo-Moreira H, Lacerda ALT, Mello AF. A Clinical Rationale for Assessing the Impact of Childhood Sexual Abuse on Adjunctive Subcutaneous Esketamine for Treatment-Resistant Depression. Front Psychiatry 2021; 12:608499. [PMID: 34483976 PMCID: PMC8415867 DOI: 10.3389/fpsyt.2021.608499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: A history of child sexual abuse (CSA) is related to higher suicide rates and poor treatment outcomes in depressed adult patients. Twenty years after the first study investigating the effects of ketamine/esketamine on depression and suicide, there is a lack of data on the CSA effects on this emerging treatment. Here, we assess the impact of CSA on adjunctive subcutaneous (SC) esketamine for treatment-resistant depression (TRD). Methods: A directed acyclic graphic (DAG) was designed to identify clinical confounders between CSA and esketamine predictors of response. The confounders were applied in a statistical model to predict depression symptom trajectory in a sample of 67 TRD outpatients. Results: The patient sample had a relatively high prevalence rate of CSA (35.82%). Positive family history of first-degree relatives with alcohol use disorder and sex were clinical mediators of the effects of esketamine in a CSA adult population. Overall, the presence of at least one CSA event was unrelated to esketamine symptom reduction. Conclusions: Unlike responses to conventional antidepressants and psychotherapy, CSA does not appear to predict poor response to esketamine.
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Affiliation(s)
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Carolina Nakahira
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Rodrigo Simonini Delfino
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Matheus Souza Steglich
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | | | - Guilherme Abdo
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - José Alberto Del Porto
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, Institute of Early Life Adversity Research, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Department of Education, ICT and Learning, Faculty of Teacher Education and Languages, Østfold University College, Halden, Norway
| | - Acioly Luiz Tavares Lacerda
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,CNS Unit, BR Trials, São Paulo, Brazil
| | - Andrea Feijo Mello
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Research and Care on Violence and Post-traumatic Stress Disorder, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
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14
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Cavenaghi VB, da Costa LP, Lacerda ALT, Hirata ES, Miguel EC, Fraguas R. Subcutaneous Ketamine in Depression: A Systematic Review. Front Psychiatry 2021; 12:513068. [PMID: 34122156 PMCID: PMC8193034 DOI: 10.3389/fpsyt.2021.513068] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/28/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Ketamine has been shown to produce a rapid and robust antidepressant effect. Though numerous routes of administration have been studied, subcutaneous (SC) has proven to be a convenient and cost-effective route making its use particularly relevant in developing countries. Here we provide a systematic review covering the use of SC racemic ketamine and esketamine in depression, including its efficacy, safety and tolerability. Methods: A systematic literature search was carried out, from inception through March, 2021, using PubMed/MEDLINE, EMBASE and Web of Science, with no limits of language. After identifying 159 potentially relevant articles, 12 articles were selected after applying our inclusion/exclusion criteria. These comprised two randomized clinical trials, five case-reports and five retrospective studies. Given the small number of studies found and their heterogeneous nature, a meta-analysis was not considered appropriate. Here we provide a synthesis of these data including participant characteristics, dose range, efficacy, safety/ tolerability. Risk of bias was accessed using the Cochrane risk of bias tool. Results: SC Ketamine was administered to unipolar and bipolar patients a single or multiple doses, weekly or twice-weekly, a dose-titration approach was made in major studies, dose ranged from 0.1 to 0.5 mg/Kg of racemic ketamine and 0.5-1 mg/Kg of esketamine. Across all studies, SC ketamine showed a rapid and robust antidepressant effect, with response/ remission rates from 50 to 100% following both single or multiple doses, with transitory side effects. Conclusion: SC racemic ketamine and esketamine in depression is a promising strategy showing beneficial efficacy and tolerability. Future studies exploring the SC route, its cost-effectiveness, and a direct comparison with IV and intranasal (IN) protocols are warranted. Systematic Review Registration: CRD42019137434.
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Affiliation(s)
| | - Leandro Paulino da Costa
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- Programa de Transtornos Afetivos, Laboratório Interdisciplinar de Neurociências Clínicas, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Edson Shiguemi Hirata
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Renério Fraguas
- Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil.,University Hospital, University of São Paulo, São Paulo, Brazil
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