Low Dose Intravenous Ketamine in Treatment Resistant Depression Patients

The primary goal of the project is to study the effect of Ketamine on cortical
neurophysiological function in Treatment Resistant Depression(TRD) patients. There are three
key preclinical findings regarding Ketamine antidepressant effects that motivate the current
study: a) low dose Ketamine causes early increase in glutamate neurotransmission; b) Ketamine
initiates synaptic plasticity; c) ketamine infusion leads to rapid improvement in depression
symptoms. The proposal essentially employs robust and non-invasive neurophysiological
techniques, Auditory Steady State Response(ASSR)-gamma oscillatory response and Transcranial
Magnetic Stimulation(TMS) cortical excitability to investigate the above findings in patients
with treatment resistant depression.

Study:

Ketamine Infusion:

We will employ an open-label study in which the infusion session, the enrolled TRD patients
will receive low dose Ketamine (0.5 mg/kg) over 40 minutes.

Cortical Excitability:

TMS stimulation will be applied to the corresponding region of the contralateral primary
motor cortex to determine motor threshold and to examine the motor cortical excitability
measures after Ketamine. The optimal coil position will be determined by moving the TMS coil
in 1-cm increments over the motor cortical area while delivering single or paired magnetic
pulses and by observing maximal contraction of the contralateral abductor pollicis brevis
(APB). Electromyography readings will be obtained from the APB muscle. TMS stimulation will
then be applied to Left DLPFC or Left Brodmann Area 6 to investigate cortical excitability
changes after ketamine. Electroencephalography(EEG) recordings will be concurrent with TMS
procedure.

ASSR/EEG paradigm:

Participants may engage in the auditory steady state response task where click trains of
500-ms duration will be presented binaurally at 65 ± 5 decibel(dB). The click train
repetition frequencies will be 40 Hz and presented in the context of an auditory oddball
paradigm to ensure participant attention to the stimuli. This task will be done while
participants undergo EEG recordings.

Inclusion Criteria:

- Be between 18-60 years of age

- Meet criteria for Treatment Resistant Depression (defined as two or more unsuccessful
trials of antidepressants at an adequate dose for at least 4 weeks)

Exclusion Criteria:

- Diagnosed with intellectual disability, eg. Mental retardation, neurodegenerative
diseases, eg. Early onset neurocognitive disturbances such as frontotemporal dementia
or behavioral disorders, eg. adult onset Attention Deficit Hyperactivity Disorder,

- Diagnosed with Bipolar Disorder (BD),

- Diagnosed with personality disorders,

- Previously or currently diagnosed with psychosis (schizoaffective disorder -SAD) or
schizophrenia - SCZ),

- Current major medical problems that affect brain anatomy, neurochemistry, or function,
e.g., obstructive sleep apnea requiring Continuous Positive Airway Pressure (CPAP),
liver insufficiency, kidney insufficiency, cardiovascular problems, systemic
infections, cancer, auto-immune diseases, and any brain disorder (seizure disorder,
stroke, dementia, degenerative neurologic diseases); history of any brain diseases,
including seizures, stroke, meningitis, encephalitis, dementia, degenerative brain
diseases, and head injury with loss of consciousness for any period of time,

- Diagnosed specifically with a cardiovascular disorders such as Hypertension,
Arrhythmias, Chronic Heart Failure, Myocardial Infarction (MI) or suffering from
Chronic Obstructive Pulmonary Disease (COPD) or asthma. Cardiac clearance prior to
enrolling in the study and medical records from physician will be required per
patient's Primary Care Physician.

- Patients with increased risk of laryngospasm, active upper respiratory infections,
respiratory depression, increased intracranial pressure, thyroid disease, or
porphyria,

- Current substance abuse or dependence. Only patients who achieved stable, full
remission for at least 6 months will be included

- Pregnancy or Breast feeding. All female in reproductive age will undergo pregnancy
tests. Female participants will be required to provide evidence of use of
contraceptives during the course of the study,

- Unable to understand the design and requirements of the study.

- Unable to sign the informed consent for any reason.