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Liu JJ, Ein N, Gervasio J, Baker C, Plouffe R, Wanklyn S, Burhan AM, Lau B, Abreu E, Wasiuta T, Nazarov A, Richardson JD. Ketamine in the effective management of chronic pain, depression, and posttraumatic stress disorder for Veterans: A meta-analysis and systematic review. Front Psychiatry 2024; 15:1338581. [PMID: 38979497 PMCID: PMC11228764 DOI: 10.3389/fpsyt.2024.1338581] [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: 11/14/2023] [Accepted: 06/03/2024] [Indexed: 07/10/2024] Open
Abstract
Introduction Ketamine has emerged as a promising treatment alternative for the management of chronic pain. Despite encouraging findings in civilian populations, and favourable results from trials examining its efficacy in military populations, there is still a dearth of information pointing to optimal specifications related to ketamine administration for pain, depression, and posttraumatic stress disorder (PTSD) in military populations. This meta-analysis and systematic review synthesised available evidence on the effectiveness, tolerability, and feasibility of ketamine in the management of chronic pain and mental health conditions in military populations. Methods This review followed the Cochrane's Guide for systematic reviews of interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as frameworks for data collection and synthesis. Results A total of 11 studies and 22 independent samples were retained for data analyses. Across samples, improvements in pain, depression, and PTSD outcomes were evident, with the use of ketamine leading to significant reductions, g = 1.76, SE = 0.19, 95% CI (1.39, 2.13), Z = 9.26, p <.001. These effect sizes were robust with moderate-to-large effects. In addition, the reductions in symptoms were observed in both active-duty and Veteran groups, and for different routes of ketamine administration, frequencies of ketamine administration, duration of ketamine treatments, dosage, study design, and allowance for concurrent treatments. Discussion This review provides a preliminary synthesis of available evidence which suggests that ketamine may be a potential option for the treatment of depression, PTSD, and chronic pain in military populations. The viability of ketamine as an alternative treatment may be particularly impactful for those who are treatment resistant, experience chronic symptoms, and/or have exhausted conventional treatments. More research is warranted in order verify the findings presented in this review.
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Affiliation(s)
- Jenny J.W. Liu
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
| | - Natalie Ein
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Julia Gervasio
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
| | - Clara Baker
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
| | - Rachel Plouffe
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
- Division of Psychology, School of Humanities, Social Sciences and Law, University of Dundee, Dundee, United Kingdom
| | - Sonya Wanklyn
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
- Operational Stress Injury Clinic, St Joseph’s Health Care, London, ON, Canada
| | - Amer M. Burhan
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Brenda Lau
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Change Pain Clinic, Vancouver, BC, Canada
| | - Emmanuel Abreu
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Change Pain Clinic, Vancouver, BC, Canada
| | - Thomas Wasiuta
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Operational Stress Injury Clinic, St Joseph’s Health Care, London, ON, Canada
| | - Anthony Nazarov
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - J. Don Richardson
- MacDonald Franklin Operational Stress Injury Research Centre, London, ON, Canada
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Operational Stress Injury Clinic, St Joseph’s Health Care, London, ON, Canada
- Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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Ackland PE, Koffel EA, Goldsmith ES, Ullman K, Miller WA, Landsteiner A, Stroebel B, Hill J, Wilt TJ, Duan-Porter W. Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder: A Systematic Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:792-812. [PMID: 37326899 DOI: 10.1007/s10488-023-01279-6] [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] [Accepted: 05/29/2023] [Indexed: 06/17/2023]
Abstract
Guidelines strongly recommend trauma-focused therapies to treat posttraumatic stress disorder. Implementation of cognitive processing therapy (CPT) and prolonged exposure (PE) in Veterans Health Administration (VHA) and non-VHA settings began in 2006. We conducted a systematic review of implementation facilitators and challenges and strategies to address barriers. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for English-language articles. Two individuals reviewed eligibility and rated quality. Quantitative results were abstracted by one reviewer and verified by a second. Qualitative results were independently coded by two reviewers and finalized through consensus. We used RE-AIM and CFIR frameworks to synthesize findings. 29 eligible studies addressed CPT/PE, mostly conducted in VHA. Training/education with audit/feedback was the primary implementation strategy and was linked to improved provider CPT/PE perceptions and self-efficacy. Use was not widespread. Only six studies tested other implementation strategies with mixed impact. Following VHA implementation, strong support for training, perceived effectiveness for patients and benefits for clinics, and positive patient experiences and relationships with providers were reported. However, barriers persisted including perceived protocol inflexibility, complex referral processes and patient complexity and competing needs. In non-VHA settings, providers perceived fewer barriers, but few were CPT/PE trained. Across both settings, fewer studies targeted patient factors. Training/education with audit/feedback improved perceptions and the availability of CPT/PE, but not consistent use. Studies testing implementation strategies to address post-training challenges, including patient-level factors, are needed. A few studies are underway in VHA to test patient-focused and other implementation strategies. Research assessing actual vs perceived barriers in non-VHA settings is needed to elucidate unique challenges experienced.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA.
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | | | - Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Wendy A Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Benjamin Stroebel
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Jessica Hill
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Psychology, Binghamton University, Binghamton, NY, 13902, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Wei Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
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