N-methyl-D-aspartate Antagonist (Ketamine) Augmentation of Electroconvulsive Treatment for Severe Major Depression
| Status: | Recruiting |
|---|---|
| Conditions: | Depression, Major Depression Disorder (MDD) |
| Therapuetic Areas: | Psychiatry / Psychology, Pulmonary / Respiratory Diseases |
| Healthy: | No |
| Age Range: | 18 - 65 |
| Updated: | 4/2/2016 |
| Start Date: | November 2010 |
Electroconvulsive therapy (ECT), is considered the most effective treatment for severe
treatment resistant major depressive disorder (MDD), but it requires about 3 weeks of
treatments and can cause considerable acute deficits in memory. It would be a major advance
in treatment if ECT could work faster with fewer treatments and result in decrease incidence
of memory problems. Ketamine is an excellent candidate for augmentation of ECT because of
its acute effects on depression, its short half-life, and its safety profile when given at
low doses. Ketamine is given as an infusion and could easily be incorporated into the
routine management of patients undergoing ECT, but has never been evaluated prospectively in
this context.
The investigators propose to assess the efficacy, feasibility, tolerability and safety of
N-methyl-D-aspartate antagonist augmentation of ECT using ketamine.
treatment resistant major depressive disorder (MDD), but it requires about 3 weeks of
treatments and can cause considerable acute deficits in memory. It would be a major advance
in treatment if ECT could work faster with fewer treatments and result in decrease incidence
of memory problems. Ketamine is an excellent candidate for augmentation of ECT because of
its acute effects on depression, its short half-life, and its safety profile when given at
low doses. Ketamine is given as an infusion and could easily be incorporated into the
routine management of patients undergoing ECT, but has never been evaluated prospectively in
this context.
The investigators propose to assess the efficacy, feasibility, tolerability and safety of
N-methyl-D-aspartate antagonist augmentation of ECT using ketamine.
Aim #1: To assess the efficacy of ketamine augmentation in reducing time to remission of a
major depressive episode (MDE).
Aim #2: To assess the efficacy of ketamine augmentation on ECT-related cognitive side
effects.
Aim #3: To assess the feasibility, safety, and tolerability of ketamine augmentation of ECT.
Exploratory aim #4: We propose to assess the patterns of functional connectivity before,
during and after ECT using standard clinical EEG to better characterize the effect of ECT
and to correlate clinical effects with changes in EEG measurements.
Thirty (30) participants will be recruited over 24 months. Participants will be males and
females, ages 18-60, with severe MDD (baseline score HAM_D-28 >= 20) deemed appropriate for
ECT treatment by their treating physician, agreeing to receive ECT treatment as part of
their clinical care, and able to provide informed consent.
Exclusion criteria are any other DSM-IV primary diagnoses including major depressive
disorder with psychotic features, bipolar disorder, schizoaffective disorder, schizophrenia,
dementia, any history of psychosis, substance use disorder (abuse or dependence with active
use within the last 6 months), and any lifetime history of ketamine abuse or dependence,
organic mental disorders, seizure disorder or chronic antiepileptic medications, severe or
unstable medical illness, pregnancy.
Study procedures: eligible patients will be randomized to a double-blind administration of
ketamine (0.5 mg/kg) or saline before the first three ECT treatments. Right Unilateral ECT
(RUL-ECT) will be administered at 6 times the seizure threshold, using the d'Elia placement
of the electrodes. Electroconvulsive therapy will be given 3 times per week, as per standard
of care at MGH. Depression severity will be assessed weekly with the HAM-D 28 (the main
outcome measure), administered by a clinician blinded to randomization.
The neuropsychological assessment battery is designed to include instruments sensitive to
the cognitive impairment associated with depression in general and ECT treatment in
particular will be repeated at baseline, at the end of acute treatment series and at 3
months follow-up.
Also patients will undergo repeated EEG monitoring, at baseline after one week of treatment
and at follow up with the aim of possibly identifying EEG features associated with response.
major depressive episode (MDE).
Aim #2: To assess the efficacy of ketamine augmentation on ECT-related cognitive side
effects.
Aim #3: To assess the feasibility, safety, and tolerability of ketamine augmentation of ECT.
Exploratory aim #4: We propose to assess the patterns of functional connectivity before,
during and after ECT using standard clinical EEG to better characterize the effect of ECT
and to correlate clinical effects with changes in EEG measurements.
Thirty (30) participants will be recruited over 24 months. Participants will be males and
females, ages 18-60, with severe MDD (baseline score HAM_D-28 >= 20) deemed appropriate for
ECT treatment by their treating physician, agreeing to receive ECT treatment as part of
their clinical care, and able to provide informed consent.
Exclusion criteria are any other DSM-IV primary diagnoses including major depressive
disorder with psychotic features, bipolar disorder, schizoaffective disorder, schizophrenia,
dementia, any history of psychosis, substance use disorder (abuse or dependence with active
use within the last 6 months), and any lifetime history of ketamine abuse or dependence,
organic mental disorders, seizure disorder or chronic antiepileptic medications, severe or
unstable medical illness, pregnancy.
Study procedures: eligible patients will be randomized to a double-blind administration of
ketamine (0.5 mg/kg) or saline before the first three ECT treatments. Right Unilateral ECT
(RUL-ECT) will be administered at 6 times the seizure threshold, using the d'Elia placement
of the electrodes. Electroconvulsive therapy will be given 3 times per week, as per standard
of care at MGH. Depression severity will be assessed weekly with the HAM-D 28 (the main
outcome measure), administered by a clinician blinded to randomization.
The neuropsychological assessment battery is designed to include instruments sensitive to
the cognitive impairment associated with depression in general and ECT treatment in
particular will be repeated at baseline, at the end of acute treatment series and at 3
months follow-up.
Also patients will undergo repeated EEG monitoring, at baseline after one week of treatment
and at follow up with the aim of possibly identifying EEG features associated with response.
Inclusion Criteria:
1. males and females between the ages of 18-65,
2. DSM-IV diagnosis of Major Depressive Disorder (MDD), without psychotic features
3. HAM-D-28 score of 20 or higher
4. requiring ECT treatment as part of their psychiatric care Comorbid anxiety disorders
(OCD, Generalized anxiety, panic disorder) will be allowed as long as the clinician
administering the SCID believes that they are not the primary diagnosis.
Exclusion Criteria:
1. MDD with a score of <20 on the HAM-D 28,
2. Other DSM-IV primary diagnoses including major depressive disorder with psychotic
features, bipolar disorder, schizoaffective disorder, schizophrenia, dementia
3. any history of psychosis
4. substance use disorder (abuse or dependence with active use within the last 6
months), and any lifetime history of ketamine abuse or dependence;
5. organic mental disorders;
6. seizure disorder or chronic antiepileptic medications;
7. severe or unstable medical illness, including history of closed head injury resulting
in loss of consciousness, medical contraindication to anesthesia or to ECT (i.e.
recent myocardial infarction, increased intracranial pressure)
8. current treatment with memantine
9. pregnancy, or females of reproductive age who are not using an accepted method of
contraception (birth control pill, IUD, combination of barrier methods).
10. known hypersensitivity to ketamine
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