Case report: Improvement in refractory functional seizures, depression, and quality of life with ketamine-assisted therapy

Functional seizures, a primary subtype of functional neurological disorder (FND), are a known cause of serious neurological disability with an increasing awareness of their impact amongst the neuroscience community. Situated at the intersection of neurology and psychiatry, FND is characterized by a range of alterations in motor, sensory or cognitive performance, such as abnormal movements, limb weakness, and dissociative, seizure-like episodes. Functional seizures are known, in part, to have psychological underpinnings; however, the lack of effective and consistent treatment options requires research and novel approaches to better understand the etiology, diagnosis and what constitutes a successful intervention. Ketamine, a selective blocker of the N-methyl-D-aspartate receptor, has a well-established safety and efficacy profile. In recent years, ketamine-assisted therapy has shown increasing potential for treating a broad range of psychiatric conditions, building on its demonstrated rapid-acting antidepressant effects. Here we present a 51-year-old female with refractory daily functional seizures leading to significant disability and a medical history significant for major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). After unsuccessful treatment attempts, the patient underwent a novel protocol with ketamine-assisted therapy. After 3 weeks of ketamine-assisted therapy followed by 20 weeks of intermittent ketamine treatment and ongoing integrative psychotherapy, the patient's seizures were significantly reduced in frequency and severity. She experienced significant improvements in depressive symptoms and functional ability scores. To our knowledge, this is the first reported case describing improvement in functional seizures following ketamine-assisted therapy. While rigorous studies are needed, this case report encourages further investigation of ketamine-assisted therapy for functional seizures and other functional neurological symptoms.

A complex peripheral code for salt taste in Drosophila

Each taste modality is generally encoded by a single, molecularly defined, population of sensory cells. However, salt stimulates multiple taste pathways in mammals and insects, suggesting a more complex code for salt taste. Here, we examine salt coding in Drosophila. After creating a comprehensive molecular map comprised of five discrete sensory neuron classes across the fly labellum, we find that four are activated by salt: two exhibiting characteristics of ‘low salt’ cells, and two ‘high salt’ classes. Behaviorally, low salt attraction depends primarily on ‘sweet’ neurons, with additional input from neurons expressing the ionotropic receptor IR94e. High salt avoidance is mediated by ‘bitter’ neurons and a population of glutamatergic neurons expressing Ppk23. Interestingly, the impact of these glutamatergic neurons depends on prior salt consumption. These results support a complex model for salt coding in flies that combinatorially integrates inputs from across cell types to afford robust and flexible salt behaviors.

Salt is essential for our survival, but too much can kill us. Our taste system has therefore evolved two different pathways to help us maintain balance. Low concentrations (like the salt on our chips) activate a pathway that makes us want to eat. But high concentrations (like the salt in seawater) activate pathways that do the opposite.

The nervous system takes on the role of detecting salt and encoding the information in a way that the brain can use. One specific type of cell detects each of the four other tastes: sweet, bitter, sour, and umami. But salt, with its two sensing pathways, is the exception to this rule. Previous work has examined salt taste responses in flies, but the picture is incomplete.

In flies, one type of taste neuron uses a different signaling mechanism to the others, suggesting that it might play a special role. So here, Jaeger, Stanley et al. asked how fly sensory cells encode salt information for the brain, and what those unusual neurons are for.

Mapping the taste receptor neurons in the tongue-like structure of the fly, the proboscis, revealed that salt information is not restricted to one or two types of cell. In fact, all five types of neurons tested (covering more than 90% of all the taste neurons present in flies) responded to salt in some way. Of these, two ‘low salt’ cell types made the fly want to eat salt, and two ‘high salt’ cell types made the fly want to avoid it. One of these high salt cell types was the unusual taste neuron identified previously. Rather than always encoding high salt as 'bad', the message from this type of cell changed depending on the diet of the fly. Salt-deprived flies ignored the activity of that cell type altogether. This complex way of encoding taste allowed the fly to change its behavior depending on how much salt it needed.

This work opens new questions, like how do the fly's neuronal circuits process this complex salt code? And how do the ‘high salt’ cells achieve their negative effect only when the need for salt is low? Understanding more about this system could lead to a better understanding of why our own brains enjoy salty foods so much.