New Frontiers in Ketamine Research: From Mechanisms of Action to Novel Psychiatric Treatment Approaches
Marcus C. Rosenhagen, Julien Elowe, Alberto Forte, Nicolas Schaad
American Journal of Psychiatry and Neuroscience August 17, 2023 DOI: 10.11648/j.ajpn.20231103.12 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Review Peer reviewed |
|---|---|
| Interventions | Ketamine S-ketamine |
| Topics | Esketamine Ketamine |
| Key findings | The review reports that ketamine shows rapid antidepressant effects, especially in treatment-resistant depression, with intravenous racemic ketamine backed by Level 1 evidence while non-intravenous formulations have limited evidence. It is recommended as a third-line option after multiple failed antidepressant trials. Preliminary evidence suggests possible benefits in obsessive-compulsive and personality disorders, though further research is needed. Side effects are generally mild and self-limiting, but caution is advised in uncontrolled hypertension, cardiovascular conditions, psychosis history, or substance abuse, and it is contraindicated in pregnancy. |
Abstract
Ketamine, initially developed as a safer alternative to phencyclidine, has emerged as a groundbreaking treatment in psychiatric practice. It gained popularity after its approval by the FDA in 1970 for its analgesic properties and ability to induce altered consciousness while maintaining vital functions. In the 1990s, researchers discovered its rapid and potent antidepressant effects, especially in patients with treatment-resistant depression. The mechanism of action of ketamine involves blocking N-Methyl-D-Aspartate receptors, leading to the release of inhibitory signals and increased glutamate levels. This process triggers a series of events promoting neuron growth and synaptic plasticity relevant to antidepressant outcomes. Various administration methods have been explored, including intravenous, intranasal, oral, subcutaneous, and intramuscular routes, each with its own advantages and limitations. IV ketamine administration has been widely used, but intranasal and sublingual forms are gaining popularity due to improved accessibility and safety. The FDA and European Medicines Agency approved intranasal S-ketamine for treatment resistant depression and depressive symptoms. Ketamine treatment is being extensively researched for its impact on various psychiatric domains, including resistant depression, suicidal crises, anxiety disorders, substance use disorders, and others. Preliminary evidence suggests potential benefits in conditions such as obsessive compulsive and personality disorders, although further research is needed. Ketamine's safety profile is generally favorable, with mild, temporary, and self-limiting side effects. However, caution is advised in individuals with uncontrolled hypertension, cardiovascular conditions, a history of psychosis, or substance abuse. Contraindications also apply to pregnant women. Ketamine interactions with other medications should be carefully considered, especially regarding benzodiazepines, and lamotrigine use. To optimize ketamine treatment in psychiatric diseases, guidelines recommend it as a third-line option after multiple unsuccessful antidepressant treatments for treatment resistant depression. Intravenous racemic ketamine has Level 1 evidence supporting its efficacy, while the evidence for non-intravenous formulations is limited. International guidelines vary slightly, but overall, the use of ketamine shows great potential in addressing challenging psychiatric conditions. This update highlights the expanding literature on ketamine in psychiatric treatment, focusing on its applications in treatment-resistant depression and its potential to revolutionize acute psychiatric emergency departments. Moreover, it provides insights into administration methods, safety considerations, and international guidelines for optimized ketamine usage in psychiatric practice.
Comparable studies
Other narrative reviews on ketamine, most cited first.
| Study | Year | Design | Participants |
|---|---|---|---|
| Ketamine and Ketamine Metabolite Pharmacology: Insights into Therapeutic Mechanisms | 2018 | Review | |
| Mechanisms of Ketamine Action as an Antidepressant | 2018 | Review | |
| Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation Adults with treatment-resistant depression | 2021 | Review | |
| Ketamine Pharmacology: An Update (Pharmacodynamics and Molecular Aspects, Recent Findings) | 2013 | Review | |
| A Consensus Statement on the Use of Ketamine in the Treatment of Mood Disorders | 2017 | Review and consensus statement |
Citations in the library
Cites 55
- A Randomized Trial of an N-methyl-D-aspartate Antagonist in Treatment-Resistant Major Depression Archives of General Psychiatry August 1, 2006
- Synaptic Dysfunction in Depression: Potential Therapeutic Targets Science October 4, 2012
- NMDAR inhibition-independent antidepressant actions of ketamine metabolites Nature April 24, 2016
- The dissociative anaesthetics, ketamine and phencyclidine, selectively reduce excitation of central mammalian neurones by N‐methyl‐aspartate British Journal of Pharmacology June 1, 1983
- Ketamine and Ketamine Metabolite Pharmacology: Insights into Therapeutic Mechanisms Pharmacological Reviews June 26, 2018
and 50 more in the library