1
|
Abstract
The discovery of the rapid antidepressant effects of the dissociative anaesthetic ketamine, an uncompetitive N-Methyl-D-Aspartate receptor antagonist, is arguably the most important breakthrough in depression research in the last 50 years. Ketamine remains an off-label treatment for treatment-resistant depression with factors that limit widespread use including its dissociative effects and abuse potential. Ketamine is a racemic mixture, composed of equal amounts of (S)-ketamine and (R)-ketamine. An (S)-ketamine nasal spray has been developed and approved for use in treatment-resistant depression in the United States and Europe; however, some concerns regarding efficacy and side effects remain. Although (R)-ketamine is a less potent N-Methyl-D-Aspartate receptor antagonist than (S)-ketamine, increasing preclinical evidence suggests (R)-ketamine may have more potent and longer lasting antidepressant effects than (S)-ketamine, alongside fewer side effects. Furthermore, a recent pilot trial of (R)-ketamine has demonstrated rapid-acting and sustained antidepressant effects in individuals with treatment-resistant depression. Research is ongoing to determine the specific cellular and molecular mechanisms underlying the antidepressant actions of ketamine and its component enantiomers in an effort to develop future rapid-acting antidepressants that lack undesirable effects. Here, we briefly review findings regarding the antidepressant effects of ketamine and its enantiomers before considering underlying mechanisms including N-Methyl-D-Aspartate receptor antagonism, γ-aminobutyric acid-ergic interneuron inhibition, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic receptor activation, brain-derived neurotrophic factor and tropomyosin kinase B signalling, mammalian target of rapamycin complex 1 and extracellular signal-regulated kinase signalling, inhibition of glycogen synthase kinase-3 and inhibition of lateral habenula bursting, alongside potential roles of the monoaminergic and opioid receptor systems.
Collapse
Affiliation(s)
- Luke A Jelen
- Department of Psychological
Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s
College London, London, United Kingdom,South London and Maudsley NHS
Foundation Trust, London, United Kingdom,Luke A Jelen, Department of
Psychological Medicine, Institute of Psychiatry, Psychology and
Neuroscience, King’s College London, 16 De Crespigny Park, London SE5
8AF, United Kingdom.
| | - Allan H Young
- Department of Psychological
Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s
College London, London, United Kingdom,South London and Maudsley NHS
Foundation Trust, London, United Kingdom
| | - James M Stone
- Department of Psychological
Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s
College London, London, United Kingdom,South London and Maudsley NHS
Foundation Trust, London, United Kingdom
| |
Collapse
|
2
|
Kokane SS, Armant RJ, Bolaños-Guzmán CA, Perrotti LI. Overlap in the neural circuitry and molecular mechanisms underlying ketamine abuse and its use as an antidepressant. Behav Brain Res 2020; 384:112548. [PMID: 32061748 PMCID: PMC7469509 DOI: 10.1016/j.bbr.2020.112548] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/18/2020] [Accepted: 02/07/2020] [Indexed: 02/09/2023]
Abstract
Ketamine, a dissociative anesthetic and psychedelic compound, has revolutionized the field of psychopharmacology by showing robust, and rapid-acting antidepressant activity in patients suffering from major depressive disorder (MDD), suicidal tendencies, and treatment-resistant depression (TRD). Ketamine's efficacy, however, is transient, and patients must return to the clinic for repeated treatment as they experience relapse. This is cause for concern because ketamine is known for its abuse liability, and repeated exposure to drugs of abuse often leads to drug abuse/dependence. Though the mechanism(s) underlying its antidepressant activity is an area of current intense research, both clinical and preclinical evidence shows that ketamine's effects are mediated, at least in part, by molecular adaptations resulting in long-lasting synaptic changes in mesolimbic brain regions known to regulate natural and drug reward. This review outlines our limited knowledge of ketamine's neurobiological and biochemical underpinnings mediating its antidepressant effects and correlates them to its abuse potential. Depression and addiction share overlapping neural circuitry and molecular mechanisms, and though speculative, repeated use of ketamine for the treatment of depression could lead to the development of substance use disorder/addiction, and thus should be tempered with caution. There is much that remains to be known about the long-term effects of ketamine, and our lack of understanding of neurobiological mechanisms underlying its antidepressant effects is a clear limiting factor that needs to be addressed systematically before using repeated ketamine in the treatment of depressed patients.
Collapse
Affiliation(s)
- Saurabh S Kokane
- Department of Psychology, The University of Texas at Arlington, United States
| | - Ross J Armant
- Department of Psychology, The University of Texas at Arlington, United States
| | - Carlos A Bolaños-Guzmán
- Department of Psychological and Brain Sciences, Institute for Neuroscience, Texas A&M University, College Station, TX 77840, United States
| | - Linda I Perrotti
- Department of Psychology, The University of Texas at Arlington, United States.
| |
Collapse
|
3
|
Sial OK, Parise EM, Parise LF, Gnecco T, Bolaños-Guzmán CA. Ketamine: The final frontier or another depressing end? Behav Brain Res 2020; 383:112508. [PMID: 32017978 PMCID: PMC7127859 DOI: 10.1016/j.bbr.2020.112508] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/15/2020] [Accepted: 01/23/2020] [Indexed: 12/12/2022]
Abstract
Two decades ago, the observation of a rapid and sustained antidepressant response after ketamine administration provided an exciting new avenue in the search for more effective therapeutics for the treatment of clinical depression. Research elucidating the mechanism(s) underlying ketamine's antidepressant properties has led to the development of several hypotheses, including that of disinhibition of excitatory glutamate neurons via blockade of N-methyl-d-aspartate (NMDA) receptors. Although the prominent understanding has been that ketamine's mode of action is mediated solely via the NMDA receptor, this view has been challenged by reports implicating other glutamate receptors such as AMPA, and other neurotransmitter systems such as serotonin and opioids in the antidepressant response. The recent approval of esketamine (Spravato™) for the treatment of depression has sparked a resurgence of interest for a deeper understanding of the mechanism(s) underlying ketamine's actions and safe therapeutic use. This review aims to present our current knowledge on both NMDA and non-NMDA mechanisms implicated in ketamine's response, and addresses the controversy surrounding the antidepressant role and potency of its stereoisomers and metabolites. There is much that remains to be known about our understanding of ketamine's antidepressant properties; and although the arrival of esketamine has been received with great enthusiasm, it is now more important than ever that its mechanisms of action be fully delineated, and both the short- and long-term neurobiological/functional consequences of its treatment be thoroughly characterized.
Collapse
MESH Headings
- Antidepressive Agents/pharmacology
- Antidepressive Agents/therapeutic use
- Depressive Disorder, Major/drug therapy
- Depressive Disorder, Treatment-Resistant/drug therapy
- Dopamine Plasma Membrane Transport Proteins/drug effects
- Excitatory Amino Acid Antagonists/pharmacology
- Excitatory Amino Acid Antagonists/therapeutic use
- Humans
- Ketamine/pharmacology
- Ketamine/therapeutic use
- Norepinephrine Plasma Membrane Transport Proteins/drug effects
- Receptor, Muscarinic M1/drug effects
- Receptors, AMPA/drug effects
- Receptors, Dopamine D2/drug effects
- Receptors, N-Methyl-D-Aspartate/drug effects
- Receptors, Opioid, delta/drug effects
- Receptors, Opioid, kappa/drug effects
- Receptors, Opioid, mu/drug effects
- Receptors, Serotonin, 5-HT3/drug effects
- Receptors, sigma/drug effects
- Serotonin Plasma Membrane Transport Proteins/drug effects
Collapse
Affiliation(s)
- Omar K Sial
- Texas A&M University: Department of Psychological and Brain Sciences, 4325 TAMU, College Station, TX, 77843, USA
| | - Eric M Parise
- Fishberg Department of Neuroscience, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Lyonna F Parise
- Fishberg Department of Neuroscience, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Tamara Gnecco
- Texas A&M University: Department of Psychological and Brain Sciences, 4325 TAMU, College Station, TX, 77843, USA
| | - Carlos A Bolaños-Guzmán
- Texas A&M University: Department of Psychological and Brain Sciences, 4325 TAMU, College Station, TX, 77843, USA.
| |
Collapse
|
4
|
Kalmoe MC, Janski AM, Zorumski CF, Nagele P, Palanca BJ, Conway CR. Ketamine and nitrous oxide: The evolution of NMDA receptor antagonists as antidepressant agents. J Neurol Sci 2020; 412:116778. [PMID: 32240970 DOI: 10.1016/j.jns.2020.116778] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 02/20/2020] [Accepted: 03/14/2020] [Indexed: 12/19/2022]
Abstract
N-methyl-d-aspartate receptor (NMDAR) antagonists, including ketamine and nitrous oxide, are currently intensely studied as rapid-acting antidepressant agents. Interestingly, both of these compounds are also drugs of abuse. Intravenous ketamine, a dissociative anesthetic that induces complex downstream effects via NMDARs, rapidly reduces depressive and suicidal symptoms in treatment-resistant depression (TRD), as demonstrated by several trials. Recently, the United States Food and Drug Administration (FDA) approved an intranasal version of ketamine (esketamine) for TRD. The United States Drug Enforcement Agency (DEA) lists ketamine as a Class III scheduled drug (moderate-low potential for physical and psychological abuse). The FDA has established a Risk Evaluation and Management Strategy (REMS) program to ensure proper drug storage, handling, dispensing, and monitoring intranasal esketamine to minimize misuse/abuse opportunities. Nitrous Oxide is a colorless, odorless, gas that has been in medical use for over 150 years. The mechanisms of action of nitrous oxide are not fully understood; however, it is known to act as a non-competitive inhibitor of NMDA-type glutamate receptors. Currently, nitrous oxide is used for inhalational general anesthesia and analgesia for short procedures. Inhaled nitrous oxide is also used recreationally, primarily by teens and young adults, but is not believed to have strong addiction potential. In contrast to ketamine, nitrous oxide is not a controlled substance and can be legally purchased without a prescription. A recent double-blind, prospective, cross-over study demonstrated that nitrous oxide reduced depressive symptoms in a group of severely ill TRD patients. Though this is a promising initial study, further investigation is needed.
Collapse
Affiliation(s)
- Molly C Kalmoe
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Alvin M Janski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Peter Nagele
- Department of Anesthesia and Critical Care, The University of Chicago Medical Center, Chicago, IL, United States of America
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America.
| |
Collapse
|