Intravenous Ketamine Plus Neurocognitive Training for Depression

Testing a Synergistic, Neuroplasticity-Based Intervention for Depressive Neurocognition

This study has two aims: 1) to characterize the effects of intravenous ketamine on neurocognitive markers in depressed patients; 2) to test the efficacy of a synergistic intervention for depression combining intravenous ketamine with neurocognitive training. Three of the primary outcomes listed (fMRI functional connectivity; Implicit Association Test; cognitive flexibility testing) pertain to Aim 1. For Aim 2, one primary clinical outcome (MADRS, a clinician-administered measure of depression severity) pertains to the acute (30-day) phase, while the QIDS (a self-report measure of depression severity) becomes the primary clinical outcome during the 12-month naturalistic follow-up.

Study Overview

• Status: Completed
• Conditions: Depression
• Intervention / Treatment: Drug: Intravenous ketamine; Behavioral: Computer-based Cognitive Training

Detailed Description

This study measures clinical and mechanistic outcome trajectories following ketamine (with or without adjunctive neurocognitive training) measured over an acute (30-day) period; and subsequently (for a subset of measures) over a 12-month naturalistic follow-up period.

NOTE: Corrections have been made to the "Time Frame" entries for all primary/secondary outcomes after identifying errors stemming from the study team's misunderstanding of the "Time Frame" query. Initially, the "Time Frame" query was misinterpreted to mean the range (minimum to maximum) length of the time interval over which any given assessment visit might query symptoms, and were therefore assigned erroneous values ("1 day to 2 weeks"; "1 day to lifetime") reflecting the time interval(s) queried by the instrument (e.g. at the +24 hours timepoint, symptoms are queried over a 1-day interval; at other assessment points, they could be queried over a 2-week interval for some measures, or over the entire lifetime for other measures). After recognizing this misinterpretation, the values have been adjusted to accurately reflect the a priori analytic plan.

• Study Type: Interventional
• Enrollment (Actual): 154
• Phase: Phase 2; Phase 1

Contacts and Locations

Study Locations

• United States
  • Pennsylvania
    • Pittsburgh, Pennsylvania, United States, 15213
      • Western Psychiatric Institute And Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 60 years (Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

Participants will:

1. be between the ages of 18 and 60 years,
2. have not responded to one or more adequate trials of FDA-approved antidepressants within the current depressive episode, determined by Antidepressant Treatment History Form
3. score ≥ 25 on the Montgomery Asberg Depression Rating Scale (MADRS)
4. score >1SD above the normative mean on the Cognitive Triad Inventory "self" subscale *OR* <1SD below the normative mean on the Rosenberg self-esteem scale
5. possess a level of understanding sufficient to agree to all tests and examinations required by the protocol and must sign an informed consent document
6. agree to sign a release of information (ROI), identifying another individual [friend, family member, etc.] as a contact person while the patient is enrolled in the study.

Exclusion Criteria:

1. Presence of lifetime bipolar, psychotic, or autism spectrum; current problematic substance use (e.g., substance use disorder); or lifetime recreational ketamine or PCP use
2. Use of a Monoamine Oxidase Inhibitor (MAOI) within the previous 2 weeks
3. Failure to meet standard MRI inclusion criteria: those who have cardiac pacemakers, neural pacemakers, cochlear implants, metal braces, or other non-MRI-compatible metal objects in their body, especially in the eye. Dental fillings do not present a problem. Plastic or removable dental appliances do not require exclusion. History of significant injury or surgery to the brain or spinal cord that would impair interpretation of results.
4. Current pregnancy or breastfeeding, or failure to engage in an effective birth control strategy throughout the duration of the study
5. Acute suicidality or other psychiatric crises requiring treatment escalation.
6. Changes made to treatment regimen within 4 weeks of baseline assessment
7. Reading level <6th grade
8. For study entry, patients must be reasonable medical candidates for ketamine infusion, as determined by a board-certified physician co-investigator during study screening. Serious, unstable medical illnesses including respiratory [obstructive sleep apnea, or history of difficulty with airway management during previous anesthetics], cardiovascular [including ischemic heart disease and uncontrolled hypertension], and neurologic [including history of severe head injury] will be exclusions.
9. Clinically significant abnormal findings of laboratory parameters [including urine toxicology screen for drugs of abuse], physical examination, or ECG.
10. Uncontrolled or poorly controlled hypertension, as determined by a board-certified physician co-investigator's review of vitals collected during screening and any other relevant medical history/records.
11. Patients with one or more seizures without a clear and resolved etiology.
12. Patients starting hormonal treatment (e.g., estrogen) in the 3 months prior to Screening. Birth control is not an exclusion.
13. Past intolerance or hypersensitivity to ketamine or midazolam.
14. Patients taking medications with known activity at the NMDA or AMPA glutamate receptor [e.g., riluzole, amantadine, lamotrigine, memantine, topiramate, dextromethorphan, D-cycloserine], or the muopioid receptor.
15. Patients taking any of the following medications: St John's Wort, theophylline, tramadol, metrizamide
16. Patients who have received ECT in the past 6 months prior to Screening.
17. Patients currently receiving treatment with vagus nerve stimulation (VNS) or repetitive transcranial stimulation (rTMS).
18. Patients taking benzodiazepines (within 8 hours of infusion) or GABA agonists

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Ketamine + Cognitive Training	Drug: Intravenous ketamine; Intravenous ketamine is given at a subanesthetic dose, which previous research suggests is safe and efficacious for rapid relief from depression.; Behavioral: Computer-based Cognitive Training; Computer-based Cognitive Training will be delivered following intravenous ketamine to test whether learning during a post-ketamine "window of opportunity" might extend relief from depression.
Sham Comparator: Ketamine + Sham Training	Drug: Intravenous ketamine; Intravenous ketamine is given at a subanesthetic dose, which previous research suggests is safe and efficacious for rapid relief from depression.
Placebo Comparator: Saline + Cognitive Training	Behavioral: Computer-based Cognitive Training; Computer-based Cognitive Training will be delivered following intravenous ketamine to test whether learning during a post-ketamine "window of opportunity" might extend relief from depression.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Montgomery Asberg Depression Scale	Clinician-rated depression (range: 0-60; higher scores = worse outcome)	Trajectories from 24 hours through Day 30 post-infusion, Day 30 reported
Executive-salience Network Functional Connectivity	fMRI measure (beta weights where larger beta weight = stronger connectivity)	Trajectories from 24 hours through Day 30 post-infusion, 24 hours reported
Implicit Self-representations	Implicit Association Test composite difference score (performance-based measure; range = -inf-inf; high score=worse outcome; negatively signed value indicates associating oneself more strongly with positive than negative attributes)	Trajectories from 24 hours through Day 30 post-infusion, Day 5 reported
Cognitive Flexibility	Neurocognitive testing via NIH Toolbox DCCS fully-corrected T-scores (range = 0-100; high score=better outcome)	Trajectories from 24 hours through Day 30 post-infusion, Day 30 reported
Quick Inventory of Depressive Symptoms	Self-reported depression (range: 0-27; higher scores = worse outcome)	Trajectories from Day 30 through 12 months post-infusion (naturalistic follow-up), Month 12 reported

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Executive-salience Network Functional Connectivity During Resting State	fMRI measure (beta weights where larger beta weight = stronger connectivity)	Trajectories from 24 hours through Day 30 post-infusion, 24 hours reported
Affective Flexibility	'D-Prime' discrimination Z-score measured via accuracy of responses during the Affective Go/No-Go task (range: -inf-inf; high score=better performance; Z-score of 0=the sample mean)	Trajectories from 24 hours through Day 30 post-infusion, Day 30 reported
PROMIS Measures-depression	Patient-Reported Outcomes Measurement Information System (PROMIS) measure: Self-reported depression T-score range: 0-100 (higher score = worse outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
PROMIS Measures-anxiety	Patient-Reported Outcomes Measurement Information System (PROMIS) measure: Self-reported anxiety T-score range: 0-100 (higher score = worse outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
PROMIS Measures-anger	Patient-Reported Outcomes Measurement Information System (PROMIS) measure: Self-reported anger T-score range: 0-100 (higher score = worse outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
PROMIS Measures-positive Affect	Patient-Reported Outcomes Measurement Information System (PROMIS) measure: Self-reported positive affect/well-being T-score range: 0-100 (higher score = better outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
PROMIS Measures-sleep Disturbance	Patient-Reported Outcomes Measurement Information System (PROMIS) measure: Self-reported sleep disturbance T-score range: 0-100 (higher score = worse outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
PROMIS Measures-cognitive Function	Patient-Reported Outcomes Measurement Information System (PROMIS) measure: Self-reported cognitive function T-score range: 0-100 (higher score = better outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
PROMIS Measures-substance Use	Patient-Reported Outcomes Measurement Information System (PROMIS) measure: Self-reported substance use Raw score range: 0-35 (higher score = worse outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
PROMIS Measures-alcohol	Patient-Reported Outcomes Measurement Information System (PROMIS) measure: Self-reported alcohol use T-score range: 0-100 (higher score = worse outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
Cognitive Triad Inventory	Negative perceptions of self, future, & world (range=36-252; higher score = better outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
Columbia-Suicide Severity Rating Scale	Suicidality and patient safety (most severe ideation score, range=0-5; higher score = worse outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
WHO Disability Assessment Scale (SR)	Global functioning (range=0-48; higher score = worse outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
Cognitive Flexibility Scale	Self-reported cognitive flexibility (range=12-72; higher score = better outcome)	Trajectories from 24 hours through Month 12 post-infusion, Month 12 reported
Neuroplasticity-related Markers in Blood	ketamine metabolite (2R,6R)-HNK concentration levels (range=0-inf; higher score = greater concentration in blood)	40min post-infusion

Collaborators and Investigators

• Sponsor: Rebecca Price
• Collaborators: National Institute of Mental Health (NIMH)

Publications and helpful links

General Publications

• Price RB, Panny B, Degutis M, Griffo A. Repeated measurement of implicit self-associations in clinical depression: Psychometric, neural, and computational properties. J Abnorm Psychol. 2021 Feb;130(2):152-165. doi: 10.1037/abn0000651. Epub 2020 Dec 3.

Study record dates

Study Major Dates

• Study Start (Actual): December 1, 2017
• Primary Completion (Actual): October 18, 2022
• Study Completion (Actual): October 18, 2022

Study Registration Dates

• First Submitted: July 28, 2017
• First Submitted That Met QC Criteria: July 28, 2017
• First Posted (Actual): August 2, 2017

Study Record Updates

• Last Update Posted (Actual): March 19, 2024
• Last Update Submitted That Met QC Criteria: February 23, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Keywords: depression; fMRI; ketamine; neurocognitive; cognitive training
• Additional Relevant MeSH Terms: Behavioral Symptoms; Mental Disorders; Mood Disorders; Depression; Depressive Disorder; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Central Nervous System Depressants; Peripheral Nervous System Agents; Analgesics; Sensory System Agents; Anesthetics, Dissociative; Anesthetics, Intravenous; Anesthetics, General; Anesthetics; Excitatory Amino Acid Antagonists; Excitatory Amino Acid Agents; Ketamine
• Other Study ID Numbers: STUDY19040414; 1R01MH113857 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: We will comply with all NIMH guidelines regarding data repository/sharing.
• IPD Sharing Time Frame: We will comply with all NIMH guidelines regarding data repository/sharing.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No