title: Ketamine administration in depressive disorders: a systematic review and meta-analysis.
abstract: BACKGROUND
  Ketamine's efficacy in depressive disorders has been established in several controlled trials. The aim of the present study was to determine whether or not ketamine administration significantly improves depressive symptomatology in depression and more specifically in major depressive disorder (MDD), bipolar depression, resistant depression (non-ECT studies), and as an anesthetic agent in electroconvulsive therapy (ECT) for resistant depression (ECT studies). Secondary outcomes were the duration of ketamine's effect, the efficacy on suicidal ideations, the existence of a dose effect, and the safety/tolerance of the treatment.
  
  
  METHODS
  Studies were included if they met the following criteria (without any language or date restriction): design: randomized controlled trials, intervention: ketamine administration, participants: diagnosis of depression, and evaluation of severity based on a validated scale. We calculated standardized mean differences (SMDs) with 95 % confidence intervals (CIs) for each study. We used fixed and random effects models. Heterogeneity was assessed using the I2 statistic.
  
  
  RESULTS
  We included nine non-ECT studies in our quantitative analysis (192 patients with major depressive disorder and 34 patients with bipolar depression). Overall, depression scores were significantly decreased in the ketamine groups compared to those in the control groups (SMD = -0.99; 95 % CI -1.23, -0.75; p < 0.01). Ketamine's efficacy was confirmed in MDD (resistant to previous pharmacological treatments or not) (SMD = -0.91; 95 % CI -1.19,-0.64; p < 0.01), in bipolar depression (SMD = -1.34; 95 % CI -1.94, -0.75), and in drug-free patients as well as patients under medication. Four ECT trials (118 patients) were included in our quantitative analysis. One hundred and three patients were diagnosed with major depressive disorder and 15 with bipolar depression. Overall, depression scores were significantly improved in the 58 patients receiving ketamine in ECT anesthesia induction compared to the 60 patients (SMD = -0.56; 95 % CI -1.10, -0.02; p = 0.04; I2 = 52.4 %). The duration of ketamine's effects was assessed in only two non-ECT studies and seemed to persist for 2-3 days; this result needs to be confirmed. Three of four studies found significant decrease of suicidal thoughts and one found no difference between groups, but suicidal ideations were only studied by the suicide item of the depressive scales. It was not possible to determine a dose effect; 0.5 mg/kg was used in the majority of the studies. Some cardiovascular events were described (mostly transient blood pressure elevation that may require treatment), and ketamine's use should remain cautious in patients with a cardiovascular history.
  
  
  CONCLUSIONS
  The present meta-analysis confirms ketamine's efficacy in depressive disorders in non-ECT studies, as well as in ECT studies. The results of this first meta-analysis are encouraging, and further studies are warranted to detail efficacy in bipolar disorders and other specific depressed populations. Middle- and long-term efficacy and safety have yet to be explored. Extrapolation should be cautious: Patients included had no history of psychotic episodes and no history of alcohol or substance use disorders, which is not representative of all the depressed patients that may benefit from this therapy.
authors.affiliation: Pôle de psychiatrie des hôpitaux universitaires H Mondor, Université Paris Est-Créteil, INSERM U955, Eq Psychiatrie Génétique, Fondation FondaMental Fondation de coopération scientifique en santé mentale, 40, rue de Mesly, 94010, Créteil, France, guillaume.fond@gmail.com.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Fond
authors.forename: Anderson
authors.initials: A
authors.lastname: Loundou
authors.forename: Corentin
authors.initials: C
authors.lastname: Rabu
authors.forename: Alexandra
authors.initials: A
authors.lastname: Macgregor
authors.forename: Christophe
authors.initials: C
authors.lastname: Lançon
authors.forename: Marie
authors.initials: M
authors.lastname: Brittner
authors.forename: Jean-Arthur
authors.initials: JA
authors.lastname: Micoulaud-Franchi
authors.forename: Raphaelle
authors.initials: R
authors.lastname: Richieri
authors.forename: Philippe
authors.initials: P
authors.lastname: Courtet
authors.forename: Mocrane
authors.initials: M
authors.lastname: Abbar
authors.forename: Matthieu
authors.initials: M
authors.lastname: Roger
authors.forename: Marion
authors.initials: M
authors.lastname: Leboyer
authors.forename: Laurent
authors.initials: L
authors.lastname: Boyer
mesh_terms: D000778:Anesthetics, Dissociative / Q000627:therapeutic use*; D000928:Antidepressive Agents / Q000627:therapeutic use*; D001714:Bipolar Disorder / Q000188:drug therapy*; D003865:Major Depressive Disorder / Q000188:drug therapy*; D061218:Depressive Disorder, Treatment-Resistant / Q000188:drug therapy / Q000628:therapy*; D004565:Electroconvulsive Therapy; D006801:Humans; D007649:Ketamine / Q000627:therapeutic use*
chemical_list: D000778:Anesthetics, Dissociative; D000928:Antidepressive Agents; D007649:Ketamine