1
|
Antos Z, Żukow X, Bursztynowicz L, Jakubów P. Beyond NMDA Receptors: A Narrative Review of Ketamine's Rapid and Multifaceted Mechanisms in Depression Treatment. Int J Mol Sci 2024; 25:13658. [PMID: 39769420 PMCID: PMC11728282 DOI: 10.3390/ijms252413658] [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: 11/17/2024] [Revised: 12/12/2024] [Accepted: 12/17/2024] [Indexed: 01/14/2025] Open
Abstract
The rising prevalence of depression, with its associated suicide risk, demands effective fast-acting treatments. Ketamine has emerged as promising, demonstrating rapid antidepressant effects. While early studies show swift mood improvements, its precise mechanisms remain unclear. This article aims to compile and synthesize the literature on ketamine's molecular actions. Ketamine primarily works by antagonizing NMDA receptors, reducing GABAergic inhibition, and increasing glutamate release. This enhanced glutamate activates AMPA receptors, triggering crucial downstream cascades, including BDNF-TrkB and mTOR pathways, promoting synaptic proliferation and regeneration. Moreover, neuroimaging studies have demonstrated alterations in brain networks involved in emotional regulation, including the Default Mode Network (DMN), Central Executive Network (CEN), and Salience Network (SN), which are frequently disrupted in depression. Despite the promising findings, the literature reveals significant inaccuracies and gaps in understanding the full scope of ketamine's therapeutic potential. For instance, ketamine engages with opioid receptors, insinuating a permissive role of the opioid system in amplifying ketamine's antidepressant effects, albeit ketamine does not operate as a direct opioid agonist. Further exploration is requisite to comprehensively ascertain its safety profile, long-term efficacy, and the impact of genetic determinants, such as BDNF polymorphisms, on treatment responsiveness.
Collapse
Affiliation(s)
| | | | | | - Piotr Jakubów
- Department of Paediatric Anaesthesiology and Intensive Therapy with Pain Division, Faculty of Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland; (Z.A.); (X.Ż.); (L.B.)
| |
Collapse
|
2
|
Medeiros GC, Demo I, Goes FS, Zarate CA, Gould TD. Personalized use of ketamine and esketamine for treatment-resistant depression. Transl Psychiatry 2024; 14:481. [PMID: 39613748 PMCID: PMC11607365 DOI: 10.1038/s41398-024-03180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 11/01/2024] [Accepted: 11/06/2024] [Indexed: 12/01/2024] Open
Abstract
A large and disproportionate portion of the burden associated with major depressive disorder (MDD) is due to treatment-resistant depression (TRD). Intravenous (R,S)-ketamine (ketamine) and intranasal (S)-ketamine (esketamine) are rapid-acting antidepressants that can effectively treat TRD. However, there is variability in response to ketamine/esketamine, and a personalized approach to their use will increase success rates in the treatment of TRD. There is a growing literature on the precision use of ketamine in TRD, and the body of evidence on esketamine is still relatively small. The identification of reliable predictors of response to ketamine/esketamine that are easily translatable to clinical practice is urgently needed. Potential clinical predictors of a robust response to ketamine include a pre-treatment positive family history of alcohol use disorder and a pre-treatment positive history of clinically significant childhood trauma. Pre-treatment versus post-treatment increases in gamma power in frontoparietal brain regions, observed in electroencephalogram (EEG) studies, is a promising brain-based biomarker of response to ketamine, given its time of onset and general applicability. Blood-based biomarkers have shown limited usefulness, with small-effect increases in brain-derived neurotrophic factor (BDNF) being the most consistent indicator of ketamine response. The severity of treatment-emergent dissociative symptoms is typically not associated with a response either to ketamine or esketamine. Future studies should ensure that biomarkers and clinical variables are obtained in a similar manner across studies to allow appropriate comparison across trials and to reduce the signal-to-noise ratio. Most predictors of response to ketamine/esketamine have modest effect sizes; therefore, the use of multivariate predictive models will be needed.
Collapse
Affiliation(s)
- Gustavo C Medeiros
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.
- Advanced Depression Treatment (ADepT) Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Isabella Demo
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Fernando S Goes
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, NIMH-NIH, Bethesda, MD, USA
| | - Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Advanced Depression Treatment (ADepT) Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Departments of Pharmacology and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| |
Collapse
|
3
|
McIntyre RS, Jain R. Glutamatergic Modulators for Major Depression from Theory to Clinical Use. CNS Drugs 2024; 38:869-890. [PMID: 39150594 PMCID: PMC11486832 DOI: 10.1007/s40263-024-01114-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/17/2024]
Abstract
Major depressive disorder (MDD) is a chronic, burdensome, highly prevalent disease that is characterized by depressed mood and anhedonia. MDD is especially burdensome as approved monoamine antidepressant treatments have weeks-long delays before clinical benefit and low remission rates. In the past 2 decades, a promising target emerged to improve patient outcomes in depression treatment: glutamatergic signaling. This narrative review provides a high-level overview of glutamate signaling in synaptogenesis and neural plasticity and the implications of glutamate dysregulation in depression. Based on this preclinical evidence implicating glutamate in depression and the rapid improvement of depression with ketamine treatment in a proof-of-concept trial, a range of N-methyl-D-aspartate (NMDA)-targeted therapies have been investigated. While an array of treatments has been investigated in registered phase 2 or 3 clinical trials, the development of most of these agents has been discontinued. Multiple glutamate-targeted antidepressants are actively in development, and two are approved. Nasal administration of esketamine (Spravato®) was approved by the US Food and Drug Administration (FDA) in 2019 to treat adults with treatment-resistant depression and in 2020 for adults with MDD with acute suicidal ideation or behavior. Oral combination dextromethorphan-bupropion (AXS-05, Auvelity® extended-release tablet) was FDA approved in 2022 for the treatment of MDD in adults. These approvals bolster the importance of glutamate in depression and represent an exciting breakthrough in contemporary psychiatry, providing new avenues of treatment for patients as first-line therapy or with either poor response or unacceptable side effects to monoaminergic antidepressants.
Collapse
Affiliation(s)
- Roger S McIntyre
- University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| | - Rakesh Jain
- Department of Psychiatry, Texas Tech University School of Medicine-Permian Basin, Midland, TX, USA.
- Texas Tech University School of Medicine-Permian Basin, 2500 W William Cannon Drive, Suite 505, Austin, Texas, 78745, USA.
| |
Collapse
|
4
|
Lopes EITC, Cavalcanti-Ribeiro P, Palhano-Fontes F, Gonçalves KTDC, Nunes EA, Lima NBDM, Santos NC, Brito AJCD, de Araujo DB, Galvão-Coelho NL. Rapid and long-lasting effects of subcutaneous esketamine on suicidality: An open-label study in patients with treatment-resistant depression. J Psychiatr Res 2024; 176:254-258. [PMID: 38901389 DOI: 10.1016/j.jpsychires.2024.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 05/23/2024] [Accepted: 06/13/2024] [Indexed: 06/22/2024]
Abstract
Therapeutics for suicide management is limited, taking weeks to work. This open-label clinical trial with 18 treatment-resistant depressive patients tested subcutaneous esketamine (8 weekly sessions) for suicidality. We noted a rapid and enduring effect of subcutaneous esketamine, lasting from one week to six months post-treatment, assessed by the Beck Inventory for Suicidality (BSI). There was an immediate drop in suicidality, 24 h following the initial dose, which persisted for seven days throughout the eight-week dosing period. Additionally, this study is the first to examine a six-month follow-up after multiple administrations of subcutaneous esketamine, finding consistently lower levels of suicidality throughout this duration. Conversely, suicidality also was measured along the 8-weeks of treatment by a psychiatrist using the Montgomery-Asberg Depression Rating Scale (MADRS), which showed significant reduction only after two treatment sessions expanding until the last session. Moreover, notably, 61% of patients achieved remission on suicidality (MADRS). These results suggest that weekly subcutaneous esketamine injections offer a cost-effective approach that induces a rapid and sustained response to anti-suicide treatment. This sets the stage for further, more controlled studies to corroborate our initial observations regarding the effects of SC esketamine on suicidality. Registered trial at: https://ensaiosclinicos.gov.br/rg/RBR-1072m6nv.
Collapse
Affiliation(s)
| | - Patrícia Cavalcanti-Ribeiro
- Laboratory of Hormone Measurement, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, RN, Brazil; Postgraduate Program in Psychobiology and Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal- RN, Brazil; Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | | | - Kaike Thiê da Costa Gonçalves
- Laboratory of Hormone Measurement, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Emerson Arcoverde Nunes
- Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, RN, Brazil; Department of Clinical Medicine, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Nicole Bezerra de Medeiros Lima
- Laboratory of Hormone Measurement, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Nestor Caetano Santos
- Laboratory of Hormone Measurement, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | | | | | - Nicole Leite Galvão-Coelho
- Laboratory of Hormone Measurement, Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal, RN, Brazil; Postgraduate Program in Psychobiology and Department of Physiology and Behavior, Federal University of Rio Grande do Norte, Natal- RN, Brazil; Western Sydney University, NICM Health Research Institute, Westmead, NSW, Australia; National Science and Technology Institute for Translational Medicine (INCT-TM), Brazil.
| |
Collapse
|
5
|
Shanok NA, Muzac S, Brown L, Barrera M, Rodriguez R. Synergistic use of deep TMS therapy with IV ketamine infusions for major depressive disorder: a pilot study. Psychopharmacology (Berl) 2024; 241:1427-1433. [PMID: 38472415 DOI: 10.1007/s00213-024-06573-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/05/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVE Major Depressive Disorder (MDD) is a pervasive psychiatric condition effecting approximately 21 million adults in the U.S. (8.4%). An estimated 30-60% of patients are resistant to traditional treatment approaches (medications and talk-therapy), alluding to the need for additional options. Two promising treatment modalities include transcranial magnetic stimulation (TMS) and ketamine infusions; both have shown efficacy in standalone studies but have scarcely been investigated synergistically in the same group of participants. METHOD In the current study, 169 participants with treatment-resistant MDD received 36 treatments of Deep TMS-only (H1 + H7 protocols), while 66 received 36 treatments of Deep TMS (H1 + H7 protocols) and 6 IV infusions of ketamine over the course of 9 weeks. Depressive symptoms were compared pre- and -post treatment in both conditions using the PHQ-9. RESULTS In both treatment groups, depressive symptoms were significantly reduced from pre-to-post and there were no significant differences in response between the TMS + ketamine condition and the TMS-only condition. The TMS + ketamine condition had an 80.30% response rate (53 out of 66) and 43.42% remission rate (28 out of 66) compared to a 76.92% response (130 out of 169) and 39.64% remission (67 out of 16) in the TMS-only condition. CONCLUSION These results support the notion that TMS treatments yield high response rates in treatment-resistant cases; however, in this investigation there was no added benefit for including 6 sessions of IV ketamine in conjunction with TMS. Future investigations using randomized-control designs and robust outcome measures are warranted.
Collapse
Affiliation(s)
| | - Sabrina Muzac
- Delray Center for Brain Science, Delray Beach, FL, USA
| | - Leah Brown
- Delray Center for Brain Science, Delray Beach, FL, USA
| | | | | |
Collapse
|
6
|
Anzolin AP, Baldez DP, Montezano BB, Kapczinski F, de Abreu PB, Kauer-Sant'Anna M. Subcutaneous ketamine reduces suicide risk and improves functioning in depression: A proof-of-concept study. Psychiatry Res 2024; 337:115915. [PMID: 38688118 DOI: 10.1016/j.psychres.2024.115915] [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: 12/28/2023] [Revised: 04/06/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024]
Abstract
This investigation explores the efficacy of subcutaneous ketamine for mitigating depressive symptoms and suicidal ideation, addressing a crucial need for rapid-onset treatments in severe depression cases. It introduces an innovative approach to administering an NMDA receptor antagonist, significantly advancing psychopharmacological methods for treating suicidal behaviors as distinct entities, even within depressive episodes. The study's objective is to assess the impact of subcutaneous ketamine on diminishing suicidal thoughts and mood symptoms during depressive episodes through a naturalistic, prospective observational design. Conducted at Hospital de Clínicas de Porto Alegre, Brazil, between 2021 and 2023, the study involved 26 patients undergoing a current depressive episode. Of these, 23 completed the acute phase of treatment, and 18 were followed up for 6 months. The treatment regimen commenced with a ketamine dose of 0.5 mg/kg, which was adjusted according to individual responses under psychiatric supervision. The findings revealed substantial decreases in Columbia Suicide Severity Rating Scale scores following multiple ketamine sessions, with most patients achieving remission after approximately eight sessions. A notable reduction in depressive symptoms was also observed. A clear dose-response relationship was established, indicating that higher doses of ketamine were associated with more significant improvements in depressive symptoms, suicidal ideation, and overall functionality. Follow-up assessments suggested that these improvements were sustained over time. The subcutaneous administration of ketamine was generally well-tolerated, with minor and short-lived side effects. The study posits that subcutaneous ketamine may present a promising solution for treating severe depression accompanied by suicidal tendencies, particularly considering its positive influence on patient functionality and well-being. This method could offer a cost-effective and accessible treatment alternative, especially relevant in settings with limited resources. Given its potential in reducing long-term disability and economic viability, the study advocates for its broader application and further validation through larger, controlled trials. Trial Registration: ClinicalTrials.gov NCT05249309.
Collapse
Affiliation(s)
- Ana Paula Anzolin
- Graduate Program in Biological Sciences: Biochemistry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Daniel Prates Baldez
- Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil; Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Bruno Braga Montezano
- Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil; Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Flavio Kapczinski
- Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil; Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Paulo Belmonte de Abreu
- Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Márcia Kauer-Sant'Anna
- Graduate Program in Biological Sciences: Biochemistry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil; Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| |
Collapse
|
7
|
Famuła A, Radoszewski J, Czerwiec T, Sobiś J, Więckiewicz G. Ketamine in Substance Use Disorder Treatment: A Narrative Review. ALPHA PSYCHIATRY 2024; 25:206-211. [PMID: 38798813 PMCID: PMC11117434 DOI: 10.5152/alphapsychiatry.2024.241522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/06/2024] [Indexed: 05/29/2024]
Abstract
Substance use disorder (SUD) continues to pose a significant global health challenge, necessitating innovative and effective therapeutic interventions. Ketamine, traditionally recognized for its anesthetic properties, has emerged as a novel and promising avenue for the treatment of SUD. This narrative review critically examines the current body of literature surrounding the use of ketamine in various forms and settings for individuals grappling with substance abuse. The review explores the neurobiological underpinnings of ketamine's potential therapeutic effects in SUD, shedding light on its impact on glutamatergic neurotransmission, neuroplasticity, and reward pathways. Special attention is given to the psychotropic and dissociative properties of ketamine, exploring their implications for both therapeutic outcomes and patient experience. Ultimately, this review aims to provide a comprehensive overview of the current state of knowledge regarding ketamine's role in the treatment of SUD, emphasizing the need for further research and clinical exploration. As we navigate the complex terrain of addiction medicine, understanding the nuances of ketamine's potential in SUD holds promise for the development of more effective and personalized therapeutic strategies.
Collapse
Affiliation(s)
- Anna Famuła
- Department of Psychiatry, Medical University of Silesia, Faculty of Medical Sciences, Zabrze, Poland
- Intravenous Ketamine Treatment Laboratory, Multispecialty County Hospital, Tarnowskie Góry, Poland
| | - Jakub Radoszewski
- Department and Clinical Division of Psychiatry and Psychotherapy of Developmental Age, Medical University of Silesia, Faculty of Medical Sciences, Katowice, Poland
| | - Tomasz Czerwiec
- Department and Clinical Division of Psychiatry and Psychotherapy of Developmental Age, Medical University of Silesia, Faculty of Medical Sciences, Katowice, Poland
| | - Jarosław Sobiś
- Department of Psychiatry, Medical University of Silesia, Faculty of Medical Sciences, Zabrze, Poland
| | - Gniewko Więckiewicz
- Department of Psychiatry, Medical University of Silesia, Faculty of Medical Sciences, Zabrze, Poland
- Intravenous Ketamine Treatment Laboratory, Multispecialty County Hospital, Tarnowskie Góry, Poland
| |
Collapse
|
8
|
Chrenek C, Duong B, Khullar A, McRee C, Thomas R, Swainson J. Use of ketamine for treatment resistant depression: updated review of literature and practical applications to a community ketamine program in Edmonton, Alberta, Canada. Front Psychiatry 2024; 14:1283733. [PMID: 38260793 PMCID: PMC10801061 DOI: 10.3389/fpsyt.2023.1283733] [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: 12/14/2023] [Indexed: 01/24/2024] Open
Abstract
Background Though intravenous (IV) ketamine and intranasal (IN) esketamine are noted to be efficacious for treatment-resistant depression (TRD), access to each of these treatments within healthcare systems is limited due to cost, availability, and/or monitoring requirements. IV ketamine has been offered at two public hospital sites in Edmonton, Canada since 2015. Since then, demand for maintenance ketamine treatments has grown. This has required creative solutions for safe, accessible, evidence-based patient care. Objectives Aims of this paper are twofold. First, we will provide a synthesis of current knowledge with regards to the clinical use of ketamine for TRD. Consideration will be given regarding; off-label racemic ketamine uses versus FDA-approved intranasal esketamine, populations treated, inclusion/exclusion criteria, dosing, assessing clinical response, concomitant medications, and tolerability/safety. Second, this paper will describe our experience as a community case study in applying evidence-based treatment. We will describe application of the literature review to our clinical programming, and in particular focus on cost-effective maintenance treatments, long-term safety concerns, routes of ketamine administration other than via intravenous, and cautious prescribing of ketamine outside of clinically monitored settings. Methodology We conducted a literature review of the on the use of ketamine for TRD up to June 30, 2023. Key findings are reviewed, and we describe their application to our ketamine program. Conclusion Evidence for the use of ketamine in resistant depression has grown in recent years, with evolving data to support and direct its clinical use. There is an increasing body of evidence to guide judicious use of ketamine in various clinical circumstances, for a population of patients with a high burden of suffering and morbidity. While large-scale, randomized controlled trials, comparative studies, and longer-term treatment outcomes is lacking, this community case study illustrates that currently available evidence can be applied to real-world clinical settings with complex patients. As cost is often a significant barrier to accessing initial and/or maintenance IV or esketamine treatments, public ketamine programs may incorporate SL or IN ketamine to support a sustainable and accessible treatment model. Three of such models are described.
Collapse
Affiliation(s)
- Carson Chrenek
- Department of Psychiatry, Misericordia Community Hospital, University of Alberta, Edmonton, AB, Canada
| | - Bryan Duong
- Department of Psychiatry, University of Alberta Hospital, University of Alberta, Edmonton, AB, Canada
| | - Atul Khullar
- Department of Psychiatry, Grey Nuns Community Hospital, University of Alberta, Edmonton, AB, Canada
| | - Chris McRee
- Grey Nuns Community Hospital, Edmonton, AB, Canada
| | - Rejish Thomas
- Department of Psychiatry, Grey Nuns Community Hospital, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Swainson
- Department of Psychiatry, Misericordia Community Hospital, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
9
|
Schwartz OS, Amminger P, Baune BT, Bedi G, Berk M, Cotton SM, Daglas-Georgiou R, Glozier N, Harrison B, Hermens DF, Jennings E, Lagopoulos J, Loo C, Mallawaarachchi S, Martin D, Phelan B, Read N, Rodgers A, Schmaal L, Somogyi AA, Thurston L, Weller A, Davey CG. The Study of Ketamine for Youth Depression (SKY-D): study protocol for a randomised controlled trial of low-dose ketamine for young people with major depressive disorder. Trials 2023; 24:686. [PMID: 37875938 PMCID: PMC10594918 DOI: 10.1186/s13063-023-07631-3] [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: 07/11/2023] [Accepted: 09/07/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Existing treatments for young people with severe depression have limited effectiveness. The aim of the Study of Ketamine for Youth Depression (SKY-D) trial is to determine whether a 4-week course of low-dose subcutaneous ketamine is an effective adjunct to treatment-as-usual in young people with major depressive disorder (MDD). METHODS SKY-D is a double-masked, randomised controlled trial funded by the Australian Government's National Health and Medical Research Council (NHMRC). Participants aged between 16 and 25 years (inclusive) with moderate-to-severe MDD will be randomised to receive either low-dose ketamine (intervention) or midazolam (active control) via subcutaneous injection once per week for 4 weeks. The primary outcome is change in depressive symptoms on the Montgomery-Åsberg Depression Rating Scale (MADRS) after 4 weeks of treatment. Further follow-up assessment will occur at 8 and 26 weeks from treatment commencement to determine whether treatment effects are sustained and to investigate safety outcomes. DISCUSSION Results from this trial will be important in determining whether low-dose subcutaneous ketamine is an effective treatment for young people with moderate-to-severe MDD. This will be the largest randomised trial to investigate the effects of ketamine to treat depression in young people. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ID: ACTRN12619000683134. Registered on May 7, 2019. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377513 .
Collapse
Affiliation(s)
- Orli S Schwartz
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.
- Orygen, Melbourne, Australia.
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia.
| | - Paul Amminger
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Bernard T Baune
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Department of Psychiatry, University of Münster, Münster, Germany
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Gillinder Bedi
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Michael Berk
- Orygen, Melbourne, Australia
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong, Australia
| | - Sue M Cotton
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Rothanthi Daglas-Georgiou
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Nick Glozier
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Australian Research Council Centre of Excellence for Children and Families Over the Life Course, Sydney, Australia
- Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ben Harrison
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Daniel F Hermens
- Thompson Institute, University of the Sunshine Coast, Sunshine Coast, Australia
| | - Emma Jennings
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Jim Lagopoulos
- Thompson Institute, University of the Sunshine Coast, Sunshine Coast, Australia
- Thompson Brain and Mind Healthcare, Sunshine Coast, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
| | - Sumudu Mallawaarachchi
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Donel Martin
- Black Dog Institute, Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - Bethany Phelan
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Nikki Read
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lianne Schmaal
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Andrew A Somogyi
- School of Biomedicine, University of Adelaide, Adelaide, Australia
| | - Lily Thurston
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| | - Amber Weller
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
- Victorian Department of Health, Melbourne, Australia
| | - Christopher G Davey
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
| |
Collapse
|
10
|
Tóth A, Sviatkó K, Détári L, Hajnik T. Ketamine affects homeostatic sleep regulation in the absence of the circadian sleep-regulating component in freely moving rats. Pharmacol Biochem Behav 2023; 225:173556. [PMID: 37087059 DOI: 10.1016/j.pbb.2023.173556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/24/2023]
Abstract
Pharmacological effects of ketamine may affect homeostatic sleep regulation via slow wave related mechanisms. In the present study effects of ketamine applied at anesthetic dose (80 mg/kg) were tested on neocortical electric activity for 24 h in freely moving rats. Ketamine effects were compared to changes during control (saline) injections and after 6 h gentle handling sleep deprivation (SD). As circadian factors may mask drug effects, an illumination protocol consisting of short light-dark cycles was applied. Ketamine application induced a short hypnotic stage with characteristic slow cortical rhythm followed by a long-lasting hyperactive waking resulting pharmacological SD. Coherence analysis indicated an increased level of local synchronization in broad local field potential frequency ranges during hyperactive waking but not during natural- or SD-evoked waking. Both slow wave sleep and rapid eye movement sleep were replaced after the termination of the ketamine effect. Our results show that both ketamine-induced hypnotic state and hyperactive waking can induce homeostatic sleep pressure with comparable intensity as 6 h SD, but ketamine-induced waking was different compared to the SD-evoked one. Both types of waking stages were different compared to spontaneous waking but all three types of wakefulness can engage the homeostatic sleep regulating machinery to generate sleep pressure dissipated by subsequent sleep. Current-source density analysis of the slow waves showed that cortical transmembrane currents were stronger during ketamine-induced hypnotic stage compared to both sleep replacement after SD and ketamine application, but intracortical activation patterns showed only quantitative differences. These findings may hold some translational value for human medical ketamine applications aiming the treatment of depression-associated sleep problems, which can be alleviated by the homeostatic sleep effect of the drug without the need for an intact circadian regulation.
Collapse
Affiliation(s)
- Attila Tóth
- In vivo Electrophysiology Research Group, Department of Physiology and Neurobiology, Institute of Biology, Eötvös Loránd University, Hungary.
| | - Katalin Sviatkó
- In vivo Electrophysiology Research Group, Department of Physiology and Neurobiology, Institute of Biology, Eötvös Loránd University, Hungary
| | - László Détári
- In vivo Electrophysiology Research Group, Department of Physiology and Neurobiology, Institute of Biology, Eötvös Loránd University, Hungary
| | - Tünde Hajnik
- In vivo Electrophysiology Research Group, Department of Physiology and Neurobiology, Institute of Biology, Eötvös Loránd University, Hungary
| |
Collapse
|
11
|
Anzolin AP, Goularte JF, Pinto JV, Belmonte-de-Abreu P, Cruz LN, Cordova VHS, Magalhaes LS, Rosa AR, Cereser KM, Kauer-Sant’Anna M. Ketamine study: Protocol for naturalistic prospective multicenter study on subcutaneous ketamine infusion in depressed patients with active suicidal ideation. Front Psychiatry 2023; 14:1147298. [PMID: 36970275 PMCID: PMC10033666 DOI: 10.3389/fpsyt.2023.1147298] [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] [Received: 01/18/2023] [Accepted: 02/22/2023] [Indexed: 03/12/2023] Open
Abstract
BackgroundPsychiatric disorders are associated with more than 90% of reported suicide attempts worldwide, but few treatments have demonstrated a direct effect in reducing suicide risk. Ketamine, originally an anesthetic, has been shown anti-suicide effects in clinical trials designed to treat depression. However, changes at the biochemical level were assessed only in protocols of ketamine with very limited sample sizes, particularly when the subcutaneous route was considered. In addition, the inflammatory changes associated with ketamine effects and their correlation with response to treatment, dose-effect, and suicide risk warrant further investigation. Therefore, we aimed to assess whether ketamine results in better control of suicidal ideation and/or behavior in patients with depressive episodes and whether ketamine affects psychopathology and inflammatory biomarkers.Materials and methodsWe report here the design of a naturalistic prospective multicenter study protocol of ketamine in depressive episodes carried out at Hospital de Clínicas de Porto Alegre (HCPA) and Hospital Moinhos de Vento (HMV). The study was planned to recruit adult patients with Major depressive disorder (MDD) or Bipolar disorder (BD) types 1 or 2, who are currently in a depressive episode and show symptoms of suicidal ideation and/or behavior according to the Columbia-Suicide Severity Rating Scale (C-SSRS) and have been prescribed ketamine by their assistant psychiatrist. Patients receive ketamine subcutaneously (SC) twice a week for 1 month, but the frequency can be changed or the dose decreased according to the assistant physician’s decision. After the last ketamine session, patients are followed-up via telephone once a month for up to 6 months. The data will be analyzed using repeated measures statistics to evaluate the reduction in suicide risk as a primary outcome, as per C-SSRS.DiscussionWe discuss the need for studies with longer follow-ups designed to measure a direct impact on suicide risk and that additional information about the safety and tolerability of ketamine in particular subset of patients such as those with depression and ideation suicide. In line, the mechanism behind the immunomodulatory effects of ketamine is still poorly understood.Trial registrationhttps://clinicaltrials.gov/, identifier NCT05249309.
Collapse
Affiliation(s)
- Ana Paula Anzolin
- Graduate Program in Biological Sciences, Biochemistry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Jeferson Ferraz Goularte
- Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
- Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Jairo Vinícius Pinto
- University Hospital, Universidade Federal de Santa Catarina (HU-UFSC), Florianópolis, Santa Catarina, Brazil
| | - Paulo Belmonte-de-Abreu
- Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Psychiatry Service, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Victor Hugo Schaly Cordova
- Psychiatry Service, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
- School of Pharmacy, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Department of Pharmacology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Lucas Sueti Magalhaes
- Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Adriane R. Rosa
- Graduate Program in Biological Sciences, Biochemistry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
- Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- School of Pharmacy, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Department of Pharmacology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Keila Maria Cereser
- Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Márcia Kauer-Sant’Anna
- Graduate Program in Biological Sciences, Biochemistry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Laboratory of Molecular Psychiatry, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
- Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- CNPq, FAPESP, CAPES, National Institute for Science and Technology in Translational Medicine (INCT-TM), São Paulo, Brazil
- *Correspondence: Márcia Kauer-Sant’Anna,
| |
Collapse
|
12
|
Can AT, Hermens DF, Lagopoulos J. A unique case of very low-dose subcutaneous ketamine use: Maintenance option of ketamine for treatment-resistant depression. Clin Case Rep 2022; 10:e6675. [PMID: 36523376 PMCID: PMC9748241 DOI: 10.1002/ccr3.6675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022] Open
Abstract
Numerous studies have demonstrated that low-dose subanesthetic intravenous ketamine infusion treatment leads to rapid improvement of treatment-resistant depression. The following case report describes the use of a very low-dose subcutaneous ketamine as a form of maintenance in a patient with severe treatment-resistant depression using a retrospective chart review.
Collapse
Affiliation(s)
- Adem T. Can
- Thompson InstituteUniversity of the Sunshine CoastBirtinyaQueenslandAustralia
| | - Daniel F. Hermens
- Thompson InstituteUniversity of the Sunshine CoastBirtinyaQueenslandAustralia
| | - Jim Lagopoulos
- Thompson InstituteUniversity of the Sunshine CoastBirtinyaQueenslandAustralia
| |
Collapse
|
13
|
Marchi M, Magarini FM, Galli G, Mordenti F, Travascio A, Uberti D, De Micheli E, Pingani L, Ferrari S, Galeazzi GM. The effect of ketamine on cognition, anxiety, and social functioning in adults with psychiatric disorders: A systematic review and meta-analysis. Front Neurosci 2022; 16:1011103. [PMID: 36507365 PMCID: PMC9730521 DOI: 10.3389/fnins.2022.1011103] [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: 08/03/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background It has been shown that ketamine can improve suicidality and depression. Evidence for other dimensions of psychopathology is lacking. We undertook a systematic review to investigate the effect of ketamine on cognition, anxiety, quality of life, and social functioning in adults with psychiatric disorders. Methods PubMed (Medline), Scopus, PsycINFO, and EMBASE were searched up to April 2022. Randomized controlled trials (RCTs) on ketamine [or its S (+) enantiomer] reporting data on cognition, anxiety, quality of life, social functioning in adults with psychiatric disorders were included. Standardized mean difference (SMD) was used for summarizing continuous outcomes. Results Twenty-two reports were included in the final selection, of which 20, corresponding to 1,298 participants, were included in the quantitative synthesis. Affective disorders were the predominant diagnostic category. Median follow-up time was 21 days. The evidence was rated moderate to very low. In most trials, ketamine was administered intravenously or as adjuvant to electro-convulsant therapy (ECT). Only 2 trials of intranasal esketamine were identified. The effect of ketamine on depression was confirmed (SMD: -0.61 [95% CI: -1.06; -0.16]). Furthermore, by pooling results of 6 RCTs, ketamine may be effective in reducing anxiety symptoms (SMD: -0.42 [95% CI: -0.84; 0.003]), particularly when administered not within ECT (5 trials; SMD: -0.58 [95% CI: -1.07; -0.09]). However, there was moderate heterogeneity of results. Patients treated with ketamine also had an improvement in social functioning (SMD: -0.31 [95% CI: -0.52; -0.10]), although the estimate was based only on 2 studies. No difference to comparators was found with respect to cognition and quality of life. Conclusion Alongside the antidepressant effect, ketamine may also improve anxiety and social functioning in adults with affective disorders.
Collapse
Affiliation(s)
- Mattia Marchi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Federica Maria Magarini
- Department of Mental Health and Drug Abuse, Azienda Unità Sanitaria Locale (AUSL) Modena, Modena, Italy
| | | | - Federico Mordenti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio Travascio
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniele Uberti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Edoardo De Micheli
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Pingani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvia Ferrari
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Gian Maria Galeazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| |
Collapse
|
14
|
Monks DT, Palanisamy A, Jaffer D, Singh PM, Carter E, Lenze S. A randomized feasibility pilot-study of intravenous and subcutaneous administration of ketamine to prevent postpartum depression after planned cesarean delivery under neuraxial anesthesia. BMC Pregnancy Childbirth 2022; 22:786. [PMID: 36271352 PMCID: PMC9587550 DOI: 10.1186/s12884-022-05118-8] [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] [Received: 02/25/2022] [Accepted: 10/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background Evidence suggests ketamine may prevent postpartum depression (PPD) after cesarean delivery (CD) although intolerability and inconvenience of administration are problematic. We assessed the feasibility of studying ketamine (0.5 mg/kg, via subcutaneous injection or 40-min intravenous infusion) to prevent PPD after CD. Methods Twenty-three women scheduled for cesarean delivery under neuraxial anesthesia were randomized to one of three groups: subcutaneous ketamine (SC Group, n = 8), intravenous ketamine (IV Group, n = 8) or placebo (n = 7). We measured depression (Edinburgh Postpartum Depression Scale [EPDS]) scores pre-operatively and at 1, 2, 21 and 42 days postoperatively. Anxiety, adverse effects, surgical site pain and analgesic consumption were also assessed. Feasibility was assessed based on acceptability, burden of disease, ability to collect study data and, tolerability of interventions. Results Baseline characteristics of groups were similar, however, more women in the placebo group had pre-existing anxiety disorder (p = 0.03). 20.7% (25/121) of those approached consented to participate and 34.8% (8/23), of those assessed, screened positive for depression in the postpartum (EPDS > 12). PPD screening data was complete in 78.3% (18/23). No differences were observed for any adverse effect outcomes except for fewer incidences of intraoperative shivering with ketamine (SC: 25%, IV: 0% and Placebo: 85.7%, p = 0.01). No statistically significant difference in positive screening for PPD was observed (SC: 14.3%, IV: 50% and Placebo: 42.9%, p = 0.58). Conclusion An RCT was judged to be feasible and there was no evidence of intolerability of either route of ketamine administration. Dispensing with the need for intravenous access makes the subcutaneous route a particularly attractive option for use in the postpartum population. Further examination of these interventions to prevent, and possibly treat, postpartum depression is warranted. Trial registration NCT04227704, January 14th, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-05118-8.
Collapse
Affiliation(s)
- David Thomas Monks
- Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.
| | - Arvind Palanisamy
- Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.,Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, USA
| | - Danish Jaffer
- Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, MO, 63110, USA
| | - Preet Mohinder Singh
- Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, MO, 63110, USA
| | - Ebony Carter
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, USA
| | - Shannon Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, USA
| |
Collapse
|
15
|
Cordova VHS, Anzolin AP, Sant'Ana MK, Lacerda A, Belmonte-de-Abreu PS. Allergic reaction induced by subcutaneous administration of ketamine: a case report. Int Clin Psychopharmacol 2022; 37:229-230. [PMID: 35503059 DOI: 10.1097/yic.0000000000000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ketamine can be used for depression and suicidal ideation due to its effectiveness and low complication rates; moreover, allergic reactions are rare. Immediately after subcutaneous (SC) ketamine administration, a 22-year-old man rapidly developed hives on the trunk and face without oxygen desaturation. Symptoms disappeared after treatment with prednisolone. This case presents an allergic reaction to ketamine compatible with mast cell activation and release of preformed mediators, without being able to prove whether the event was mediated by immunoglobulin E. This is the only case reported to date of an allergic reaction to SC ketamine for psychiatric treatment.
Collapse
Affiliation(s)
- Victor Hugo Schaly Cordova
- Pharmacy School, Universidade Federal do Rio Grande do Sul
- Post-Graduate Program in Psychiatry and Behavioral Sciences, Universidade Federal do Rio Grande do Sul
- Hemoterapy Service, Hospital de Clínicas de Porto Alegre
| | - Ana Paula Anzolin
- Post-Graduate Program in Biology Sciences: Biochemestry, Universidade Federal do Rio Grande do Sul, Porto Alegre
| | - Marcia Kauer Sant'Ana
- Hemoterapy Service, Hospital de Clínicas de Porto Alegre
- Post-Graduate Program in Biology Sciences: Biochemestry, Universidade Federal do Rio Grande do Sul, Porto Alegre
| | - Acioly Lacerda
- Departamento de Psiquiatria, Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
| | | |
Collapse
|
16
|
Tham JCW, Do A, Fridfinnson J, Rafizadeh R, Siu JTP, Budd GP, Lam RW. Repeated subcutaneous racemic ketamine in treatment-resistant depression: case series. Int Clin Psychopharmacol 2022; 37:206-214. [PMID: 35695279 DOI: 10.1097/yic.0000000000000409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Interest in the use of parenteral ketamine has been increasing over the last 2 decades for the management of treatment-resistant depression (TRD). While intravenous (IV) ketamine has been the most common parenteral route of administration, subcutaneous (SC) and intramuscular options have been described. We developed a clinical treatment protocol for the use of repeated SC racemic ketamine (maximum six treatments, twice per week) in an inpatient psychiatric care setting with inclusion/exclusion criteria, dosing schedule, and description of treatment, assessment, and monitoring procedures. Results from the first 10 consecutive patients demonstrated the effectiveness of SC racemic ketamine in relieving symptoms of TRD as measured by the Montgomery-Åsberg Depression Rating Scale (MADRS) and Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR 16 ). Response (≥50% reduction in scores from baseline to endpoint) was achieved in 8/10 cases on the MADRS and 6/10 on the QIDS-SR 16 . Remission was achieved in 8/10 (based on MADRS ≤10) and 5/10 (based on QIDS-SR 16 ≤6). Patients tolerated the treatments well with only transient blood pressure changes and dissociative side effects. Repeated SC ketamine treatments could be a safe, feasible, and effective alternative to IV ketamine infusions for patients with TRD.
Collapse
Affiliation(s)
- Joseph C W Tham
- BC Neuropsychiatry Program, University of British Columbia
- VGH/UBC Neurostimulation Program, University of British Columbia, Vancouver
| | - André Do
- Department of Psychiatry, Université de Montréal, Montreal
| | - Jason Fridfinnson
- Department of Anesthesiology and Perioperative Care (VGH and UBC), University of British Columbia
| | - Reza Rafizadeh
- BC Mental Health & Substance Use Services, Lower Mainland Pharmacy Services
| | - Jacky T P Siu
- Tertiary Mental Health & Substance Use, Lower Mainland Pharmacy Services, University of British Columbia
| | - George P Budd
- Mental Health and Substance Use Services, Vancouver Coastal Health
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| |
Collapse
|
17
|
Corwell BN, Motov SM, Davis N, Kim HK. Novel uses of ketamine in the emergency department. Expert Opin Drug Saf 2022; 21:1009-1025. [PMID: 35822534 DOI: 10.1080/14740338.2022.2100883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Ketamine is gaining renewed interest among healthcare providers due to its novel clinical applications in the emergency department (ED) setting. AREAS COVERED : This article provides a comprehensive discussion of ketamine's pharmacological properties, including safety profile and adverse effects, in addition to an overview of current evidence for ketamine (racemic formulation) in the management of ED patients with acute agitation, pain, and depression/suicide ideation. EXPERT OPINION : Ketamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. As an analgesic agent, administration of ketamine (0.1-0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain. Moreover, ketamine provides equal analgesic efficacy to morphine in a variety of chronic painful conditions including pain associated with cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency. Available literature shows that ketamine (1-2mg/kg IV or 4-5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have a potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.
Collapse
Affiliation(s)
- Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Natalie Davis
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
18
|
Shamabadi A, Ahmadzade A, Aqamolaei A, Mortazavi SH, Hasanzadeh A, Akhondzadeh S. Ketamine and Other Glutamate Receptor Modulating Agents for Treatment-Resistant Depression: A Systematic Review of Randomized Controlled Trials. IRANIAN JOURNAL OF PSYCHIATRY 2022; 17:320-340. [PMID: 36474699 PMCID: PMC9699814 DOI: 10.18502/ijps.v17i3.9733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/01/2021] [Accepted: 01/05/2022] [Indexed: 06/17/2023]
Abstract
Objective: Available treatments of depression have limited efficacy and unsatisfactory remission rates. This study aims to review randomized controlled trials (RCTs) investigating effects of glutamate receptor modulators in treating patients with resistant depression. Method : The study protocol was registered in PROSPERO (CRD42021225516). Scopus, ISI Web of Science, Embase, Cochrane Library, Google Scholar, and three trial registries were searched up to September 2020 to find RCTs evaluating glutamate receptor modulators for resistant depression. The difference between intervention and control groups in changing depression scores from baseline to endpoint was considered the primary outcome. Version 2 of the Cochrane risk-of-bias tool for randomized trials was used to assess the quality of the RCTs. No funding was received. Results: Thirty-eight RCTs were included. Based on the included studies, compelling evidence was found for ketamine (with or without electroconvulsive therapy, intravenous or other forms), nitrous oxide, amantadine, and rislenemdaz (MK-0657); the results for MK-0657, amantadine, and nitrous oxide were only based on one study for each. Lithium, lanicemine, D-cycloserine, and decoglurant showed mixed results for efficacy, and, riluzole, and 7-chlorokynurenic acid were mostly comparable to placebo. A limited number of studies were available that addressed drugs other than ketamine. Conclusion: The study cannot determine the difference between statistical and clinical significance between the agents and placebo due to high heterogeneity among the RCTs. Nevertheless, ketamine could be used as an efficacious drug in TRD; still, additional studies are needed to delineate the optimum dosage, duration of efficacy, and intervals. Further studies are also recommended on the effectiveness of glutamatergic system modulators other than ketamine on treatment-resistant depression.
Collapse
Affiliation(s)
- Ahmad Shamabadi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Ahmadzade
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Aqamolaei
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyyed Hosein Mortazavi
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Hasanzadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Akhondzadeh
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
19
|
Potential advantages of ketamine over electroconvulsive therapy in the treatment of nonrefractory severe depression in older patients with multiple medical comorbidities. CNS Spectr 2022; 28:313-318. [PMID: 35492018 DOI: 10.1017/s1092852922000773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Depression in older adults with multiple medical comorbidities can contribute to clinical deterioration, and increased mortality. Electroconvulsive therapy (ECT) is the first-line treatment for these patients. This study aimed to evaluate the effectiveness and safety of subcutaneous (SC) ketamine as an alternative to ECT. We reviewed the medical records of all consecutive older inpatients with severe depression and multiple medical comorbidities who were referred for ECT but treated with SC ketamine over 1 year in our institution. Demographic data, DSM-5 diagnosis, MÅDRS score, and CGI score were analyzed. Twelve patients aged 67-94 years were included. All patients were rated as severely ill, 83% were women, with a mean of 12.6 (SD, 1.4) medical comorbidities. Remission was achieved in 75% of the intention-to-treat population and 100% of treatment completers. The number of sessions ranged from 1 to 6, and days until remission from 1 to 16. Patients remained without relapse for 8-28 months. SC ketamine was safe and well tolerated, and most adverse events were mild and transient. Although limited by the retrospective open-label design of the study and small sample size, our findings provide a potential new indication for ketamine: treatment of severe depression, not necessarily resistant to antidepressants, in older patients with multiple medical comorbidities, at risk of clinical deterioration, and referral for ECT. SC ketamine was highly effective in this population, with no relapse and good tolerance. Randomized controlled trials are needed to adequately test the use of ketamine in this specific group.
Collapse
|
20
|
Kritzer MD, Pae CU, Masand PS. Key considerations for the use of ketamine and esketamine for the treatment of depression: focusing on administration, safety, and tolerability. Expert Opin Drug Saf 2022; 21:725-732. [PMID: 35475388 DOI: 10.1080/14740338.2022.2069749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Racemic ketamine, a derivative of phencyclidine, has been used as a dissociative anesthetic since 1970. In 2000, the first randomized controlled trial showed a rapid relief of depressive symptoms. Since then, intravenous ketamine and intranasal S-ketamine have been validated for the treatment of depression and suicidal ideation following dose-response and double-blind placebo-controlled clinical trials. In clinical practice, after dose titration and with repeated treatments, patients may experience approximately 2-3 weeks of symptomatic relief from depression. AREAS COVERED Areas covered in this narrative review include mechanism of action, dosing, safety, and tolerability. Some attention is paid to the possibility of R-ketamine as a future antidepressant. EXPERT OPINION We recommend further investigation into treatment dosing and frequency strategies as well as approaches that prolong the therapeutic effects. The current fixed dosing of esketamine for obese individuals may be insufficient. Additional investigation into co-administration with somatic and neuromodulation treatments needs investigation. Finally, continuing to monitor research subjects and patients long-term for the emergence of adverse effects on cognition or other organ systems is critical.
Collapse
Affiliation(s)
- Michael D Kritzer
- Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Prakash S Masand
- CEO, Centers of Psychiatric Excellence (COPE), New York, New York, USA.,Duke-NUS (National University of Singapore), Singapore
| |
Collapse
|
21
|
Hassan K, Struthers WM, Sankarabhotla A, Davis P. Safety, effectiveness and tolerability of sublingual ketamine in depression and anxiety: A retrospective study of off-label, at-home use. Front Psychiatry 2022; 13:992624. [PMID: 36245861 PMCID: PMC9554222 DOI: 10.3389/fpsyt.2022.992624] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Intravenous and intranasal ketamine have been shown to be effective therapeutic options in patients suffering from treatment-resistant depression (TRD). The use of sublingual (SL), rapid dissolve ketamine tablets (RDT) offers a novel approach for delivery for mental health indications. This study assessed the effectiveness and safety of self-administration of off-label, SL, rapid dissolve ketamine tablets (RDT) at-home for depression and anxiety. Intake scores on the Generalized Anxiety Disorder Screener (GAD-7) and Patient Health Questionnaire (PHQ-9) were compared to scores after treatments of three doses of ketamine RDT, and after six doses of ketamine RDT. After three doses of SL ketamine, 47.6% of patients showed a significant decrease in PHQ-9 scores, and 47.6% of patients showed a significant reduction in GAD-7 scores. Reduction rates were higher in those patients who completed a clinically recommended six doses of RDT ketamine. This study demonstrates that SL ketamine is a novel, safe, and effective treatment for TRD and treatment-resistant anxiety. SL ketamine offers an alternative therapeutic approach to IV ketamine when treating those with TRD.
Collapse
|
22
|
Cigognini MA, Guirado AG, van de Meene D, Schneider MA, Salomon MS, de Alexandria VS, Adriano JP, Thaler AM, Fernandes FDS, Carneiro A, Moreno RA. Intramuscular ketamine vs. escitalopram and aripiprazole in acute and maintenance treatment of patients with treatment-resistant depression: A randomized double-blind clinical trial. Front Psychiatry 2022; 13:830301. [PMID: 35935445 PMCID: PMC9354749 DOI: 10.3389/fpsyt.2022.830301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Ketamine, an N-methyl D-aspartate (NMDA) receptor antagonist, can promote rapid action in the management of individuals with treatment-resistant depression (TRD) at sub-anesthetic doses. However, few studies have investigated the long-term use of ketamine administered intravenously (IV) and intranasally (IN). We report the design and rationale of a therapeutic trial for assessing the efficacy, safety, and tolerability of repeated-dose intramuscular (IM) ketamine vs. active treatment (escitalopram and aripiprazole) in TRD patients. METHODS A comparative, parallel-group, randomized double-blind trial assessing the efficacy, safety, and tolerability of acute (4 weeks) and maintenance (24 weeks) use of IM ketamine (0.75 mg/kg) vs. active control (escitalopram 15 mg and aripiprazole 5 mg) in individuals with moderate-severe intensity TRD (no psychotic symptoms) with or without suicide risk will be conducted. Patients with TRD (18-40 years) will be randomized and blinded to receive ketamine IM or active treatment at a 1:1 ratio for 4 weeks (active treatment) and 24 weeks (maintenance treatment). Subjects will be assessed using clinical scales, monitored for vital signs (VS) after application of injectable medication, and undergo neuropsychological tests. The primary outcome will be changed on the Montgomery-Åsberg Depression Rating Scale (MADRS) during the course of the trial. The study is in running. RESULTS This study can potentially yield evidence on the use of IM ketamine in the treatment of depressive disorders as an ultra-rapid low-cost therapy associated with less patient discomfort and reduced use of medical resources, and can elucidate long-term effects on different outcomes, such as neuropsychological aspects. CONCLUSIONS The trial can help promote the introduction of a novel accessible approach for the treatment of complex disease (TRD) and also allow refinement of its long-term use. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT04234776, identifier: NCT04234776.
Collapse
Affiliation(s)
- Marco Aurélio Cigognini
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Alia Garrudo Guirado
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Denise van de Meene
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Mônica Andréia Schneider
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Mônica Sarah Salomon
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Vinicius Santana de Alexandria
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Juliana Pisseta Adriano
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Ana Maria Thaler
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Fernando Dos Santos Fernandes
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Adriana Carneiro
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Ricardo Alberto Moreno
- Mood Disorders Unit (GRUDA), Institute and Department of Psychiatry, School of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| |
Collapse
|