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Meshkat S, Haikazian S, Di Vincenzo JD, Fancy F, Johnson D, Chen-Li D, McIntyre RS, Mansur R, Rosenblat JD. Oral ketamine for depression: An updated systematic review. World J Biol Psychiatry 2023; 24:545-557. [PMID: 36651238 DOI: 10.1080/15622975.2023.2169349] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
Objectives: Ketamine is a glutamate N-methyl-D-aspartate receptor antagonist that can be used to treat major depressive disorder by single or repeated infusions. However, the accessibility and scalability of oral ketamine make it preferred over intravenous ketamine. In this systematic review, we aim to evaluate the efficacy, tolerability, and safety of oral ketamine, esketamine and r-ketamine for unipolar and bipolar depression. Materials and methods: Electronic databases were searched from inception to September 2022 to identify relevant articles. Results: Twenty-two studies, including four randomized clinical trials (RCTs), one case series, six case reports, five open-label trials and six retrospective chart review studies involving 2336 patients with depression were included. All included studies reported significant improvement following ketamine administration. Ketamine was well tolerated without serious adverse events. However, RCTs had a high risk of bias due to analysis methods and adverse events monitoring. Ketamine dosage varied from 0.5 to 1.25 mg/kg. The frequency of administration was daily to monthly. Several important limitations were identified, most notably the small number of RCTs. Conclusions: Taken together, preliminary evidence suggests the potential for antidepressant effect of oral ketamine. However, further research with large sample size and long follow-up period is needed to better determine the antisuicidal effect and efficacy in treatment-resistant depression.
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Affiliation(s)
- Shakila Meshkat
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
| | - Sipan Haikazian
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
| | - Farhan Fancy
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Danica Johnson
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
| | - David Chen-Li
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
- Brain and Cognition Discovery Foundation, Toronto, Canada
| | - Rodrigo Mansur
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
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Nuñez NA, Joseph B, Pahwa M, Seshadri A, Prokop LJ, Kung S, Schak KM, Vande Voort JL, Frye MA, Singh B. An Update on the Efficacy and Tolerability of Oral Ketamine for Major Depression: A Systematic Review and Meta-Analysis. Psychopharmacol Bull 2020; 50:137-163. [PMID: 33012876 PMCID: PMC7511150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Intravenous Ketamine has shown robust antidepressant efficacy although other routes of administration are currently needed. We conducted a systematic review and meta-analysis of studies evaluating the efficacy and tolerability of oral ketamine for depression. METHODS A comprehensive search of major electronic databases from inception to April 2020 was performed. Studies of oral ketamine for depression, from case series to randomized clinical trials, were eligible. Randomized controlled trials were included in a meta-analysis, focusing on response, remission, time to effect, and side effects. RESULTS A total of 917 articles were identified with 890 studies screened, yielding a total of 10 studies included in our systematic review.Three randomized controlled trials (RCTs) (N = 161, mean age 37.9 ± 9.5 years, 58.6% females) were included in the meta-analysis. Pooled analysis suggested a significant antidepressant effect of oral ketamine (SMD: -0.75; 95% CI: -1.08, -0.43; p<0.0001; I2 = 0%) although remission rates (RR:2.77; 95% CI:0.96, 8.00; p = 0.06) and response rates (RR:2.58; 95% CI:0.94,7.08; p = 0.07) were marginal compared to placebo at the endpoint. Oral ketamine antidepressant effects seemed to take effect at the 2nd week (SMD: -0.71; 95% CI: -1.08, -0.35; p = 0.001; I2 = 0%). There were no significant differences in the overall side-effects between oral ketamine and the placebo group (RR 1.28, 95% CI: 0.89-1.83; p = 0.19). CONCLUSION This focused meta-analysis of oral ketamine suggests a marginal efficacy for major depressive disorder without increased risk of adverse events. Further larger sample studies are needed to confirm these preliminary findings, analyzing differential response/remission rates by affective disorder, optimal dosing strategies, and its long-term effects.
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Affiliation(s)
- Nicolas A Nuñez
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Boney Joseph
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Mehak Pahwa
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Ashok Seshadri
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Larry J Prokop
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Simon Kung
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Kathryn M Schak
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jennifer L Vande Voort
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Mark A Frye
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Balwinder Singh
- Nuñez, MD, MS, Pahwa, MD, Seshadri, MD, Kung, MD, Schak, MD, VandeVoort, MD, Frye, MD,Singh MD, MS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA. Joseph, MBBS, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA. Prokop, MLS, Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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